Inspection on 04/05/05 for Willow Garth Care Home

This inspection was carried out on 4th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Willow Garth Care Home 23/09/08

Willow Garth Care Home 25/09/07

Willow Garth Care Home 26/09/06

Willow Garth Care Home 12/12/05

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Willow Garth Rolston Road Hornsea East Yorkshire HU18 1XH Lead Inspector Lynne Busby Unannounced 4 May 2005 09:15 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Willow Garth Address Rolston Road Hornsea East Yorkshire HU18 1XH 01964 534651 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Hatzfeld Care Limited Position Vacant Care Home 23 Category(ies) of MD Mental Disorder (23) registration, with number of places Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three (3) names service users in category MD(E) may be accommodated within the maximum number. This condition to cease when the named individuals cease to live at the home. Date of last inspection 10/11/04 Brief Description of the Service: Willow Garth is located in a rural setting close to the town of Hornsea on the coast of East Riding of Yorkshire. The home is registered for 23 service users (male and female) who have mental health needs. Personal care is provided for all service users along with all meals and a laundry service. Local facilities are only accessible via a bus. The home has a mini bus to transport service users; some service users choose to walk to town and this is on a badly lit road. Accommodation is provided in 17 single rooms and 3 shared rooms; communal space is available in two lounges, a dining room and a smoking area, which is in a walkway/conservatory. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was completed as part of the programme of inspections for the year. It was an unannounced inspection undertaken by two inspectors, Lynne Busby and David White. The inspection day lasted from 9.40 am until 4.45 pm. During the inspection a number of service users were spoken with, and four were engaged in longer conversations with the inspectors. The inspection process included a review of the documentation, a tour of the premises and discussions with the staff on duty and the cook. What the service does well: What has improved since the last inspection? What they could do better: Whilst some improvements have been made in the home there are still a number of outstanding requirements from previous inspections. More information in care plans and risk assessments is required so staff can meet service users needs. These need to be in place and regularly reviewed. The redecoration programme should continue and outstanding repairs completed. Service users advised that the food was ‘OK’ but little choice is offered particularly for those service users who have special dietary needs. The Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 6 maintenance person does regular fire tests but these records are not held on the premises so could not be checked. Staff must be employed correctly to ensure that service users are protected. The acting manager of the home has not been registered with CSCI. There is a requirement to have a registered manager. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3, and 5 Service user cannot make a fully informed choice until the service users guide is improved. Service user needs cannot be met until the assessment and care planning are fully completed. EVIDENCE: The home has a statement of purpose available and a service users guide. There are copies of a service users guide available in the dining room. These were reviewed in February 2005 but require further information to be included. The needs assessment still requires amendment to include details about compatibility with others living in the home. The service users files indicated that a person who is competent to do so undertakes assessments and the files tracked had care management plans in place. One service users file identified the health care needs but not how these needs were to be managed. Two service users spoken to knew about their individual plan and one was not aware they had one. Two service user files did not contain an individual service users plan based on the care management assessment and care plan, or the home’s own needs assessment. One service user had been in the home for four months but did not have a care plan. The inspectors were informed that both service users were still accommodated on a trial basis. The home does not place any restrictions on the service users’ choice and freedom. There were risk assessments on some service users files but not all Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 9 service users, where risks had been identified. The risk assessments in place had not been signed and have not been reviewed and updated. The staff spent time with the service users, both individually and in groups and were communicating effectively. The home have one service user where English is their second language and staff advised that the service user has a very good understanding of English but chooses not to speak. Staff are able to communicate with this service user to ascertain their needs. The home has provided information on advocacy services for the service users and information is provided in the service users guide. Service users can access specialist services and for those service users who are on the Care Programme Approach, community psychiatric nurses (CPN) have a regular input into the service users care. There is a copy of the statement of terms and conditions in the service users guide. There were no completed copies available for inspection to determine if these had been signed by the service user or their representative. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,8 and 9 Service users are consulted and participate in all aspects of life in the home and are supported to take risks as part of an independent lifestyle. On admission not all service users have an individual plan that clearly identifies how their needs will be met. EVIDENCE: There are individual plans of care available for most service users with the exception of those service users who are accommodated on a trial basis. The individual care plans inspected did set out how current and anticipated specialist requirements for service users would be met. There are no records to indicate that service users are involved in the development of their individual plans of care. Service users all have a keyworker and the service users spoken to, confirmed this. The plan is reviewed every three to six months. A service user advised that they are aware of the reviews. Since the previous inspection the home incorporate the CPN notes into the main care plan. Service users are consulted about the day-to-day running of the home and there are service users meetings held, the last one was the 1/4/05. There was no recorded evidence of feedback about the outcomes of the service users involvement in decision-making activities such as staff meetings. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 11 There were risk assessments on file but these were found not to be signed and some had not been reviewed regularly. For some service users risks had been identified but a risk assessment had not been completed. In discussion with the staff they were aware of risks and service users are encouraged and supported to take responsible risks as park of their individual lifestyle. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13,14 and 17 Service users choose to take part in leisure activities in the local community. The meals are adequate but do not offer a reasonable choice for service users on a special diet. EVIDENCE: Some service users visit the local town of Hornsea on a regular basis. The home has a mini-bus and trips are arranged for service users to go on. However, in discussion with the staff a few service users take up the option to go on trips out. Some service users go to kingfisher lodge (day centre) to participate in social activities. There is a notice board where events are posted - there was a clothes and toiletries party advertised that would take place in the home, also the local vicar attends regularly this has been arranged by one of the service users. The home is beginning to introduce to service uses in long-term placements a seven-day holiday. One couple is going for a week to a coastal resort. It is envisaged this will be extended to other service users. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 13 Service users are on the electoral register and two service users advised the inspectors that they could vote in the elections. Service users explained that the food at the home was ok, with some choice. The cook is new to the job and has only been employed for a week. Menus are being changed and inspector were informed that these would be seasonal and she is hoping to introduce a selection of fresh fruit. In discussion with the cook, there is usually one choice offered at lunchtime, and an alternative is given if the service user requests it. Some service users require special diets; it would be beneficial for all staff that caters cater for service users to have updated training in providing for all dietary needs. Menus were not displayed -some service users knew what was for lunch, others were unsure. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20 Service users can retain, administer and control their own medication. The physical and emotional health needs of service users are met. EVIDENCE: The service users are registered with a local GP and have access to the community health team. Service users have access to dentists, opticians and chiropodists. Service users on the care programme approach have reviews with a community psychiatric nurse (CPN) and the home has access to a psychiatric consultant. Service users who spoke to the inspectors are aware of their medical conditions for example diabetes. This is monitored closely by the staff and health appointments are made for the service users. There is presently one service user who self-administers and the staff monitors this. Lockable storage is provided in service users bedrooms so that they can store medication. The medication system has recently been changed and is a NOMAD system. The records checked indicated that the records for medication received, administered and leaving the home are appropriately completed. The only exception was one service user who had refused medication for one day - this Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 15 had not been entered on records. The home has no controlled drugs at present but a lockable storage and controlled drugs register is available if required. It was noted that one-service users often refuses medication for two days. There is no plan in place to state how this is to be managed. The staff member informed the inspector that service users who refuse are referred to a CPN after 24 hours. The medication policy indicates that this requires further development to include information and guidance for staff around refusal of medication, covert administration of medication and retention of medication for seven days after the death of a service user. This was identified at the last inspection. The staff had not all had accredited medication training. The inspectors were informed that staff are to attend a 14-week training course in the near future. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Service users know how to complain and are confident their complaint will be listened to. Staff are aware of the protection of vulnerable adults procedures to protect service users living in the home from abuse and neglect. EVIDENCE: The service users advised the inspectors they know how to make complaint. The complaint procedure is displayed on the notice board and is also available in the service users guide. The procedure needs to be updated to include timescales within which complaints will be responded to and the Commission for Social Care Inspection’s local contact address. There has been one complaint in the last year that was made to CSCI, this was referred back to the provider to investigate. This was investigated and a response was sent to the complainant. In addition, three complaints were made at the home. The recordings of these did not include the details of the investigation or action taken and outcome. The home has a copy of the Hull and East Riding Protection of Vulnerable Adults procedure in addition the home has its own procedures available for staff. There were no policies and procedures regarding service users money and financial affairs. Staff spoken to demonstrated a clear understanding of protection of vulnerable adults and whistle blowing. Three staff members have attended training on protection of vulnerable adults. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,26,27 and 30 Service users live in a comfortable environment and the home is clean and hygienic. Service users bedrooms suit their lifestyle and promote independence. The bathrooms and toilets provide sufficient privacy. EVIDENCE: The home has undergone some changes since the previous inspection with shared rooms being separated into single rooms. Improvements have been made to the small lounge which has been redecorated and furnished. This now provides a quiet room. The service user rooms are decorated in individual colours and in those newly decorated the service users had chosen their own colour scheme. These reflect the different styles and tastes of the service users. There is a range of furniture available in individual rooms and service users can personalise their rooms. The decisions regarding the provision of furnishings and fittings to each room must be agreed and documented in each service users care plan. Service users rooms are fitted with locks that are accessible to staff in emergencies and service users are given a key unless a risk assessment suggests otherwise. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 18 There are three bathrooms and a shower room available for service users. The bathrooms and toilet facilities are fitted with locks that staff can override in emergencies. There was one toilet that was broken and one toilet were the taps had been removed from the washbasin. These required attention the inspector was informed by a staff member that the maintenance person was aware that these required repairing. Some areas of the home require redecoration including the rear stairs and hallway and an area outside a ground floor room where the decoration had become damaged because of a water leak. The home was clean and free from offensive odours. There is a laundry that is fitted with a washer that has a specified programme to meet disinfection standards. One service user currently completes their washing. The staff informed the inspectors that this was risk assessed and always supervised. The inspectors noted that all the cleaning materials are also stored in the laundry and not separately locked away. One service user informed the inspectors that they would like to do their own laundry but could not because of the health and safety issues with the cleaning materials. The home is set in extensive grounds and access is via a long drive from the main road. At the top of the driveway is the car park. The driveway and car park is unlit. This was identified at the last inspection and could constitute a safety risk to service users, staff and visitors. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,34,35 and 36 People living in the home are not fully protected because recruitment practice and selection of staff does not follow procedures. Staff are not fully supervised and trained to meet individual and joint needs of service users. EVIDENCE: The home has a recruitment and selection procedures available including an equal opportunities policy. The inspector checked four staff files. Two did not contain any evidence that CRB checks had been undertaken. One staff member had only one written reference; the second was verbal only. Staff files need to be completed, up dated and have all necessary checks carried out for each employee before new staff are confirmed in post. Only one staff member had a job description and statement of terms and conditions. Staff have been given a copy of the General Social Care Council code of conduct. The staff rota was available for inspection. This indicated that there are two care staff on at all times in addition there is a domestic and a cook. At the inspection the domestic was on leave and therefore staff were undertaking this role. At weekends the cook only works one day so the care staff complete the catering. This leaves one care staff member in the home. The deployment of staff needs to be reviewed. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 20 The home has a training and development programme and the inspectors were informed that a range of mandatory training is being made available to all staff. There was no evidence that training needs assessment for the staff team as a whole has been carried out. There were induction and foundation training packages to TOPSS standards but no evidence these had been implemented. The staff informed the inspectors they have no formal supervision. There were no records seen of supervision. This was identified at the last inspection. The staff informed the inspectors that appraisals are to be completed. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38, 39,40 and 42 The management of the home is improving and offers service users a safe environment and their health and welfare is promoted. Service user views are listened to. EVIDENCE: The home has an acting manager who has been in post for ten months. The acting manager has not applied for registration with CSCI although this has been discussed with the provider. Since taking up post the manager has implemented a number of changes staff advised the inspectors that there is “a better atmosphere – service users are involved more in decision making”. Service users also felt supported by the acting manager and gave positive comments. The provider visits the home regularly but regulation 26 visits are not recorded. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 22 The home has recently been visited by the local authority quality development scheme. The staff informed the inspectors that the acting manager is developing an in house quality assurance system. The inspector could not fully assess this as information was not easily available. This aspect of the service will be reviewed at the next inspection. Not all the requirements have been completed within the timescales. There was evidence that staff had completed mandatory training. However, there is not always a qualified first aider on duty at all times. There were maintenance certificates for portable appliance testing, emergency lighting and fire extinguishers. The gas certificate and electrical installations certificate must be forwarded to CSCI. The fire alarm and evacuation records were held with the maintenance person who was not on site during the inspection. There are policies and procedures available in the home but these to be reviewed to meet the National Minimum Standards and appendix 1. It was noted by the inspectors that some service users smoke in other parts of the home other than the designated smoking area. Staff informed the inspectors that this is constantly dealt with. Risk assessments need to be in place where service users choose not to follow the policy on smoking. Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 1 3 x 1 Standard No 22 23 ENVIRONMENT Score 1 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 x 3 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 1 3 x x 3 Standard No 11 12 13 14 15 16 17 x x 3 3 x x 3 Standard No 31 32 33 34 35 36 Score 1 x 3 1 1 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Willow Garth Score x 3 1 x Standard No 37 38 39 40 41 42 43 Score 1 3 1 1 x 1 x J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 24 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 4,5,6 Requirement The service users guide must comply with standards 1.1 to 1.3 of the National Minimum standards and associated Care Homes Regulations 2001.(Previous requirement timescale of 1/02/05 - not met) The registered provider must ensure that the needs assessment covers all aspects of the standard and service users are involved in the development of the individual plan (Previous requirement- timescale of1/2/05 - not met). The information regarding the management of assessed health needs must be more explicit. The registered provider must ensure that service users have a copy of the contract, which has been signed by the service user and the registered manager.(Previous requirement timescale 1/02/05 - not met). Individual plans that are generated from the care management assessment or the homes assessment must be in place irrespective of how long the service user has been Timescale for action 30/06/05 2. 2 14(1) 3(1)(a) 30/06/05 3. 4. 2 5 14 14,15 30/06/05 15/06/05 5. 6 14,15 15/06/05 Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 25 accommodated. 6. 6 14,15,17 The registered provider must ensure that service users are supported in drawing up of the care plan. (Previous requirement - timescale 1/02/05 - not met). The registered provider must ensure risk assesmnets are in place in line with service users needs. These must be consistently signed and dated.(Previous requirement timescale 1/02/05- not met). The registered provider must ensure that risk management strategies are agreed, recorded in the individual plan and reviewed.(Previous requirement - timescale 1/02/05- not met). The registered provider must develop the medication policy and procedure to include information and guidance for staff around refusal of medication, covert administration of medication and retention of medication for seven days after the death of a service user. (Previous requirement timescale 1/02/05 - not met). The registered provider must ensure that care staff (responsible for the administration of medication), receive accredited medication training. (Previous requirement timesacle 1/02/05 - not met). The complaints procedure must include timescale for a reponse and records must include the investigation undertaken and the outcome. The registered provider must ensure access to and from the home is safe and consider how the driveway to the car park can be adequately lit. (Previous requirement - timescale 1/02/05 30/06/05 7. 9 13,14 15/06/05 8. 9 13,14 30/06/06 9. 20 13 schedule3 (3)(i) 31/06/05 10. 20 18 31/07/05 11. 22 17 30/06/05 12. 24 13,23,39 31/07/05 Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 26 - not met). 13. 24 23 The home requires redecoration in the rear stairs and hallway. A maintenance plan must be in place. The registered provider must provide the service users with the minimum bedrooms furnishings outlined in the standard or provide written evidence in the individuals care plan where this has been agreed otherwise or deemed unsafe (Previous requirement timescale 1/02/05 -not met). The registered provider must ensure that staff have clearly defined job descriptions and understand their own and others roles and repsonsibility. (Previous requirement timescale 1/02/05 - not met). The registered provider must ensure that recruitment procedure is followd and staff files contain all the information and necessary checks in regulations 18, 19 and schedule 2 of Care Homes Regulations 2001. (Previous requirement timescale 1/02/05 - not met). The registered provider must ensure that every staff member has an individual training and development profile and a training needs assessment is carried out for the staff team as a whole. (Previous requirement timescale 1/02/05 - not met) The registered provider must ensure staff receive the support and supervison they need to carry out their jobs. (Previous requirement - timescale 1/02/05 - not met). The registered provider must ensure that effective quality assurance and quality monitoring 31/08/05 14. 26 16,23 31/07/05 15. 31 18,19 31/07/05 16. 34 18,19 30/06/05 17. 35 18 31/07/05 18. 36 12,18 30/06/05 19. 39 12,15,24 1/06/05 Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 27 20. 21. 40 42 22. 42 23. 42 24. 37 systems, based on seeking the views of the service users, are in place to measure the success in achieving aims, objectives and statement of purpose of the home. (Previous requirement timescale 1/06/05). 17 Policies and procedures must be in line with the National Minimum standards. 17, 23 Copies of the gas certificate and electrical installations certificate must be forwarded to CSCI. The fire records must be kept on the premises. 13 Risk assessments must be in place where service users choose to not follow the policy on smoking. 13 A qualified first aider must be available at all times. (Previous requirement - timescale 1/04/05 - not met). Section 11 The registered provider must Chapter ensure a manager is registered 14, Part 2 with the Commission for the Social Care Inspection. of the Care Homes Regulation s 31/07/05 30/06/05 30/06/05 31/07/05 31/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 17 32 33 Good Practice Recommendations The registered provider should display the menus for service users. Guidance should be provided to catering staff on specialist dietary needs. 50 of the care staff should have NVQ level 2 by the end of 2005. The registered provider should review the deployment of staff at weekends. J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 28 Willow Garth Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection Unit 3, Hesslewood Country Office Park Ferriby Road Hessle East Yorkshire, HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Willow Garth J53_s62723_Willow Garth_v227264_040505_Stage 4.doc Version 1.30 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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