Inspection on 25/10/07 for Willow House

This inspection was carried out on 25th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Willow House 11 Osborne Road Enfield Middlesex EN3 7RN Lead Inspector Wendy Heal Key Announced Inspection 25th October 2007 9:30 Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 1 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 Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 2 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 Stationery 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 House DS0000068774.V346547.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow House Address 11 Osborne Road Enfield Middlesex EN3 7RN 020 8482 4112 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (If applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Connifers Care Limited Sanjeev Sunil Soobdhan Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is a new service. Brief Description of the Service: Willow House is part of Connifers care. It is a home that is registered to provide care for up-to-five people who have experienced mental health problems. Willow House is located in Brimsdown, which is in the Borough of Enfield It is in walking distance of Enfield Highway and Edmonton shopping centre. The home has five bedrooms two of which have an en-suite shower. There is a kitchen with an integral dinning area. There is a kitchen, which leads onto a lawned garden with a covered patio area. There is a staff office and adequate bathroom facilities. The stated aim is to offer care and support in a supportive and friendly environment. The service works towards meeting service users needs by encouraging user involvement and exercising choice and independence whilst building on key daily living skills to enable independent living in the community. The purpose and function document and inspection report will be available to be viewed in the entrance of the home and in the staff office. This report can also be viewed on the CSCI website. The fees range from eight hundred and seventy five pounds per week to seventeen hundred pounds per week. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place as part of the inspection programme. Compliance was checked against key standards. The inspection took approximately 8 hours. The team leader and on call manager assisted me throughout the inspection as the registered manager was on annual leave. I undertook a tour of the building, interviewed people living in the home. I observed the interaction between people living and working in the home. Further information was obtained by an inspection of the documentation kept in the home including care plans, risk assessments and health and safety documentation. I would like to thank all of those present during the inspection for their openness and participation. What the service does well: People’s care plans are up-to-date and reflect their current and changing needs, which, ensures their individual, needs can be met. Staff working in the home are good at supporting people to develop their independent living skills, which increases their confidence and self-esteem. Medication is effectively managed which protects people’s health and well being. The staff encourage contact to be maintained between people living in the home and their friends and family, which benefits their emotional wellbeing. The home is well maintained and comfortable which makes it a pleasant place to live. There is an effective complaints procedure which means complaints are taken seriously and people feel valued. The home has available the adult protection policy and procedure and staff have received training in relation to this which means people living in the home can be protected from potential abuse. People are protected by adequate recruitment policies and procedures being in place. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 6 Staff are adequately trained to meet people’s individual needs, which improves the quality of care provided. Staff receive regular supervision, which ensures that staff follow a consistent approach when supporting the people who live in the home, which improves the quality of care provided. Health and safety is taken seriously and effective health and safety records are in place, which ensures that the health and safety of the people living in the home is not compromised. What has improved since the last inspection? What they could do better: The Registered Manager must ensure that all required risk assessments are in place to ensure that the potential risks to people living in the home are minimised, which will benefit their health and well - being. The Registered Manager must ensure that behaviour guidelines are in place when people living in the home have the potential to exhibit aggressive or inappropriate behaviour, which will ensure that the staff have been provided with clear information with regard to how to respond in such situations. The recoding of the activities must be fully documented and include when a person living in the home declines to take part in a planned activity to ensure that a clear picture of the opportunities available to people living in the home can be seen. The people living in the home must ensure all their health care appointments take place to ensure that their health care needs are met. The Registered manager should consider reviewing the menu and food brought to ensure that people are provided with a healthy diet low in sugar and salt, which will benefit the health and wellbeing of people living in the home. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, People who use this service receive a good outcome. This judgement has been made using available evidence including a visit to this service. People are provided with all of the information they need to enable them to make an informed choice about were they want to live. Assessments are undertaken prior to people moving into the home, which assists staff to meet people’s individual needs. EVIDENCE: This was the first inspection of this service. The home is registered to accommodate five people who have experienced mental health problems. I looked at the statement of purpose, which was last updated, 24/09/07 and is currently being further expanded to include information in relation to the terms and conditions of people who may wish to live in the home. The address and details of the Commission For Social Care Inspection, which are going to be included in the complaints section which will enable people to contact the commission if they are unhappy with regard to how a complaint has been responded to by the organisation. There must also be information contained within the section related to staffing to ensure staff have an adequate process in place to enable them to receive advice and practical support when an emergency occurs. The emergency on call procedure is going to be included in this section of the document. As this task is currently being undertaken a requirement has not been made in relation to these areas. The service has its own brochure, which explains the homes mission, values and approach. There is also a service user guide which explains were the home is located. This Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 10 explains what the home offers, which includes information regarding the accommodation provided to people who may wish to live in the home. This document explains what makes a person eligible for a place at the home and explains the assessment and admission process and confirms how fees will be paid which ensures that people are provided with up-to-date information about the organisation to enable they to make a decision as to whether the service can meet their individual needs. If English is not a persons first language then the document can be translated on request, which ensures that the document is accessible to all those people who may wish to use it. The people living in the home are assessed before they receive a service, which ensures that their individual needs can be met by the staff that are employed to support them. On the day of the inspection I examined the homes files and saw evidence of assessments completed by the homes manager. This included information, obtained from other health professionals with knowledge of the individual people concerned. Additional information in relation to people’s specific needs had been obtained which included an occupational therapy report and discharge summaries from Barnet Enfield and Haringey NHS trust. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9, People who use this service receive an adequate outcome. This judgement has been made using available evidence including a visit to this service. The care plans are clear and up-to-date. People make decisions about their lives with assistance. However further improvements need to be made in relation to supporting people to take risks to develop an independent lifestyle. One person needs behaviour guidelines to be developed. EVIDENCE: Peoples care plans were inspected and were clear to read. The care plans highlight the identified needs, the objectives to address the identified need and steps that need to be taken to resolve the identified issues. The care plans have an evaluation date recorded on them and are signed by the identified person. Their individual key worker ensures they are fully informed and involved in the care planning process. Information contained within the plan refers to the history of the person and their mental state, health needs, dietary needs, medication, personal care, activities and social skills. The care plans were being kept up-to-date which ensures peoples individual and changing needs can be met. This improves the quality of life for the people living in the home. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 12 On the day of the inspection people demonstrated that they make decisions and choices about their daily lives. The home has a service user meeting and the events of this meeting are recorded by one of the people who lives in the home, which empowers him. The risk assessments to identify the potential risks for the individual people living in the home are being kept up-to-date which assists to minimise the potential risks of harm for people living in the home and those people working with them. However some new risk assessments need to be developed. The risks identified included, a history of drug misuse, poor compliance with oral medication, failure to eat properly, previous incidents of violence, difficulty managing physical health. One person who is insulin dependent and does not have an insight into his personal health and as a consequence does not eat a healthy diet e.g. does not eat sugar free foods and needs this information to be linked to his risk assessment using guidance and information obtained from the diabetic nurse in relation to his required diet. The current risk assessment does refer to a sugar free healthy diet but does not have the necessary information to link this with the menu planning. There is also no guidance with regard to the instances when healthy eating does not take place. There is no information to indicate how the person’s knowledge with regard to the importance of their diet is going to be developed. This is essential given the impact that poor management of his diabetes has had on his health to date. Another person who refuses to attend their medical appointments needs to have a risk assessment completed to ensure that any potential risks to his health and wellbeing are minimised. This is further referred to in the health section. One person who is identified, as having specific challenging behaviour must have behaviour guidelines developed which are specific in relation to the behaviours that the person can exhibit. The guidelines must indicate how these inappropriate behaviours are to be responded to. They must explain the process for receiving assistance when required including when the emergency on call procedure is to be followed and specify how information is to be recorded. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17, People who use the service receive a good outcome. This judgement has been made using available evidence including a visit to this service. People are supported to develop their individual skills within the home. People are part of the community and participate within that community. People are encouraged to take part in age peer and culturally appropriate activities. The service tries to assist people to maintain their family relationships. Improvements need to be made to ensure people choose healthy nutritious meals. EVIDENCE: At Willow house people are supported to develop their individual living skills. They assist with their laundry and the cleaning of their bedroom. People living in the home have their own activity plan. One person’s plan indicates how they are supported to make lunch, help to cook dinner for the other people living in the home which improves their life skills and increases their self-esteem. There are specific times identified to allow people to have their own allocated chill out time, which benefits their wellbeing as it encourages them to relax. One person is being encouraged to attend the leisure centre as noted on their activity plan but this as yet is not being undertaken by the person concerned. As the relationships of those living and working in the home develop I will be Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 14 expecting the activities being undertaken by those living in the home to be further developed. There is also a movie night on a Saturday evening, which allows all of the people living in the home to spend some social time together. Some of the people living in the home had recently undertaken a trip to Southend, which was a new experience for them and increases their life experiences. A number of people have it identified in their activity plan to have lunch or dinner out. The daily records indicated that people had eaten lunch or dinner out, been shopping, gone to the café and taken part in cookery sessions overseen by staff. This expands their opportunity to take part in activities within the local community. Not all of the activities are recorded in sufficient detail to provide the person reading the document with of a picture of what happened on the activities. The recordings do not indicate when people decline to take part in an activity. The recording of activities needs to be expanded to provide a clearer picture of all of the events undertaken to provide a clear account of the opportunities provided to people living in the home In June the people living in the home went on holiday to Caster in Norfolk, which provided them with a positive experience in a new environment. On the day of the inspection one person was being visited by their priest who visits weekly which ensures that this person’s rights and religious choices are respected. People living in the home are encouraged to maintain contact with their relatives. One person visits their mother and sister on a weekly basis. One person has regular contact with their friends and also maintains contact with his girlfriend who he goes out with at weekends which further benefits his emotional wellbeing. This person’s girlfriend has made a request via her social worker to move into the home to be with her boyfriend. The home is currently assessing the possibility of this taking place. On the day of the inspection the kitchen was clean and tidy and food was stored appropriately and within sell by date, which benefits people’s health and wellbeing. People who live in the home benefit from a mixed staff team who bring a range of different ideas to the home in terms of food preparation. This means people have access to different types of food than they may otherwise experience. The menu of food available was inspected the meals are varied however do not indicate how the needs of those people who require a sugar free diet are specifically provided for. I noted that many of the foods available were value brands, which do not assist those wishing to ensure they are provided with a healthy diet as these items often contain high levels of sugar and salt. I recommend that the food brought is reviewed by the manager of the home to improve the health of the people living in the home. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 15 Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, People who use the service receive an adequate outcome. This judgement has been made using available evidence including a visit to this service. People receive support in a way they prefer and require. Support is provided to people to access healthcare appointments but improvements need to be made with regard to this for one person. People are protected by the homes policies and procedures for dealing with medicines. EVIDENCE: The record of health appointments for each person was inspected. I saw evidence that people had registered with their general practioner, optician and one person also been referred to eye care specialists. One person receives support from the diabetic nurse. People had visited the chiropodist. People’s weight programme was being monitored along with their blood pressure recordings, which were being effectively recorded. One person had not registered with the dentist and had missed the appointment to see the general practioner. Their health needs to be more effectively monitored. As stated previously one person who refuses to attend medical appointments must have a risk assessment completed in relation to this to ensure any potential risk to this person’s health is minimised. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 17 The home has an effective policy and procedure in relation to medication. The medication cupboard and administration records were inspected. The medication was found to be appropriately stored and effectively recorded on the medication administration records. The side effects of the medication being taken were also noted on people’s individual records. The medication records were highlighted with people’s individual photographs to limit errors being made with regard to medication being given to the wrong person. There were guidelines in place in relation to the use of PRN medication, which ensures that professional practice is being followed. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23, People who use this service receive a good outcome. This judgement has been made using available evidence including a visit to this service. People can be confident that their views are listened to and acted upon. People are protected from abuse neglect and self-harm. EVIDENCE: I looked at the complaints file and was informed that no complaints had been made. The service has a complaints procedure that is on the notice board in the hall way and also provided to the people who live in the home in their individual information pack, which is given to them when they move into the home. The staff at Willow house have attended protection of vulnerable adults training. The local authority adult protection procedures were available “you have the right not to be abused”. The organisation also has its own policy document in relation to safeguarding adults and preventing abuse. The home has a whistle blowing policy and procedure, which contains the name and address of the Commission For Social Care Inspection. This means that people living in the home are supported by staff that have the necessary guidance and training to protect them from potential abuse. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30, People who use this service receive a good outcome. This judgement has been made using available evidence including a visit to this service. The home is comfortable for people to live in. People’s bedrooms suit their individual needs and lifestyles and promote their independence. People have adequate bathroom and shower facilities. The home was clean and hygienic. EVIDENCE: Willow house is a five-bedroom house located in a residential street and is in keeping with the surrounding premises. The location of the home provides good access to local amenities, including shops, pubs, and local transport which assists people to play an active part in the local community. People living in the home have their own bedroom. Two of the bedrooms have an ensuite shower and the other bedrooms have a sink fitted in them which ensures that people’s personal care needs can be met. There is one toilet and bathroom upstairs and one downstairs toilet and shower room. One the day of the inspection having sought peoples permission I inspected the bedrooms. The bedrooms were found to be appropriately furnished and had been personalised with items, which people value which make feel at home. One Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 20 person spoken with said,” I am very happy with my bedroom this is a nice place to live.” The lounge was appropriately equipped with sofa’s a television video, DVD, and hi-fi-center, curtains and wood flooring, which made the room comfortable and homely. The kitchen which has an integral dining area was appropriately furnished with a table and chairs a fridge, fridge freezer and was found to be clean and tidy on the day of the inspection, which benefits people’s health and wellbeing. The home has an office equipped with a telephone computer and photocopier to assist people to carry out their daily work. There is also a large garden laid to lawn and there is also a large covered patio area for people to relax in. The service has made an application to expand the home to provide a six bedroom, a conservatory, smoking room and lounge for those people who do not smoke which will improve the facilities provided to the people living in the home. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 21 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36, People who use the service receive a good outcome. This judgement has been made using available evidence including a visit to this service. Competent and qualified staff support people who live in the home. People are protected by the homes recruitment policy and procedures. People living in the home benefit from well supported and supervised staff. EVIDENCE: The staff rota was inspected and there were adequate numbers of staff to meet people’s needs. Staff files were inspected. All staff had criminal record bureau checks and two staff references. The files contained sufficient proof of identity either in the form of a passport or driving licence and the person’s photograph was on their individual file. The files contained the person’s contract of employment, which was signed along with their application for employment and staff induction, which ensures that the people living in the home are protected from potential abuse. The staff training records were inspected. Four staff had completed their NVQ level 2. Staff had completed training in relation to fire safety, moving and handling, mental health awareness, control and restraint, managing challenging behaviour, training regarding the mental capacity act, medication Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 22 diabetes, food hygiene and protection of vulnerable adults, which ensures that they have the necessary skills and knowledge to ensure that people’s needs can be met and improve the quality of care provided to people living in the home. Staff supervision records were inspected and staff are receiving regular supervision which ensures that there is a regular consistent approach undertaken by the staff members and assists with the personal development of those people living in the home. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 23 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42, People who use the service receive a good outcome. This judgement has been made using available evidence including a visit to this service. People who live in the home benefit from a well run service. People can be confident that their views underpin monitoring review and development within the home. The health safety and welfare of people living in the home is promoted and protected. EVIDENCE: People benefit from a well run home. The manager is a registered nurse. The manager was on leave at the time of the inspection. I was therefore assisted by the homes team leader and on call manager who supplied the information above. The organisation holds monthly managers meetings, which assists the managers to work together in a consistent way for the benefit of the people living in the home. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 24 There is a monthly quality assurance meeting to discuss the standardisation of all documents, forms and policy and procedures. A quality assurance form had been sent to all of the people living in the home and stakeholders. The information received is then made into a summary and the required action is taken to improve the quality of care provided in the home as well as highlight the areas at which the home and the staff are succeeding. There is also a suggestions box in the home for the people living in the home to make suggestions in relation to how the care and quality of life for those people living in the home can be improved. I inspected a range of health and safety documentation. The portable appliance-testing certificate, the gas and electrical certificate, which were found to be in order. The fire extinguishers had been serviced, the weekly alarm test had taken place, the smoke detectors had been checked, and the fire drills had taken place. All written recordings had been noted in relation to the above. The home has been inspected by the fire service and a copy of the homes fire risk assessment has been sent to them, which ensures that the health and safety of the people living in the home is taken seriously. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 2 X Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 26 NO 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 YA9 Regulation 15 Timescale for action The Registered Person must 01/12/07 ensure that the risk assessment is developed to ensure that the person who is insulin dependent has obtained the necessary guidance from the diabetic nurse with regard to eating a sugar free diet, which is then linked with his menu plan. The Registered Person must 01/12/07 ensure that the person who does not attend all of their medical appointments has a risk assessment completed to minimise all of the potential risks to their health. The Registered Person must 25/11/07 ensure that the identified person who can exhibit inappropriate behaviour has guidelines develop to assist staff with information in relation to how this behaviour is best managed. The Registered Person must 20/11/07 ensure that activities are fully recorded on the activity sheet including when an activity is declined. The Registered Person must 20/11/07 ensure that people’s health care DS0000068774.V346547.R01.S.doc Version 5.2 Page 27 Requirement 2. YA9 15 3 YA9 15 4. YA41 17 5. YA19 13 Willow House appointments are kept up to date. 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 Refer to Standard YA17 Good Practice Recommendations The Registered Manager should review the menu and not continue to buy value food, which can be high in sugar and salt content. Willow House DS0000068774.V346547.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 House DS0000068774.V346547.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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