Inspection on 05/01/07 for Willow House

This inspection was carried out on 5th January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Ruskin Lodge

Clover House

Dystlegh Grange

The Good Companions

Cuerden Grange Rest Home

Springfield Cottage

Parkside

Park Lodge

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

CARE HOME ADULTS 18-65 Willow House Sunflower Grove, off Hunt Lane Chadderton Oldham OL9 0JQ Lead Inspector Michelle Haller Unannounced Inspection 05th January 2007 10:00 Willow House DS0000067768.V325972.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 DS0000067768.V325972.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 DS0000067768.V325972.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow House Address Sunflower Grove, off Hunt Lane Chadderton Oldham OL9 0JQ 0161 911 4750 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) Oldham M.B.C. Debra Messam Care Home 5 Category(ies) of Learning disability (5), Physical disability (5) registration, with number of places Willow House DS0000067768.V325972.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The service should at all times employ a suitably qualified and experienced manager who is registered with the commission for social care inspection. The service is registered to provide personal care for service users who fall into the categories: Adults with learning disabilities LD (5) and Adults with physical disabilities PD (5). No service user may be permanently accommodated in the service. Date of last inspection New service Brief Description of the Service: Willow House is a newly built and furnished two-storey property situated in a quiet cul-de-sac in Chadderton, Oldham. The service is registered to provide respite (short stay) support for up to 5 people with learning disabilities who may also have physical disabilities. Oldham Metropolitan Borough Council (OMBC) owns and manages the service. There is ample parking to the front and pleasant gardens at the side and rear of the building. The private accommodation is comprised of one flat and three large wellfurnished bedrooms with en-suite facilities on the ground floor and another self-contained flat on the first floor. There is also a staff “sleeping-in” room. The home is fully adapted for any person using a wheelchair and provides very comfortable and flexible communal accommodation for all service users. Service users generally receive short stay support in the home for periods of between one day and two weeks. The fees payable were not available to the inspector. The reader is advised to contact Oldham Council regarding fees payable. An inspection report is not available as this is the first key inspection of the service. Willow House DS0000067768.V325972.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection which included an unannounced site visit to the service started on the 5th January 2007 and concluded with a visit to meet and talk with service users and relatives on 9th January 2007. During the course of the inspection the case files of six service users, policies and procedures and other reports relevant to the support of service users and the running of the service were looked at. Service users were discretely observed, as was the interaction between service users and staff. One relative and two members of staff were interviewed and a discussion with the manager also occurred. A tour of the building was completed. Survey questionnaries were left at the service for people using or visiting the service to complete with their views. Owing to the complex disabilities of the service users using the facility at the time of the inspection they were not able to comment directly about the care they received. Observations of their behaviour and relationships with staff were observed. What the service does well: The service makes sure that the needs of the service users can be met by doing a detailed assessment of need. These assessments include gathering information on the service user’s social, health, communication and psychological needs. The manager makes sure that other people who are best qualified to help with assessments do so. The service makes every effort to get to know the service users and enable the service user to become familiar with the staff and service prior to taking full responsibility for providing a period of care. This allows the service user and relatives to feel comfortable about their time at Willow House. The service is flexible and responds to the needs and developments in the lives of people who access the service and makes every effort to provide the service requested by the individual, and will advocate with service users if necessary. It was felt that the management was approachable and that staff were capable doing their jobs. There was a high level of satisfaction with the quality of support and services provided. The service maintains appropriate links with the main carers and other professionals. Willow House DS0000067768.V325972.R01.S.doc Version 5.2 Page 6 The service promotes the community presence of service users and supports them in maintaining a lifestyle in keeping with their expectation. The service also promotes the development of new skills through supporting people in trying out a variety of activities some of which are new to them. The service provides excellent accommodation that fully meets the needs of those who spend time there. The service protects service users from abuse through their recruitment process, the policies and procedures pertaining to adult protection and having a core of staff who are well informed, confident and feel able to inform managers about any concerns. The service provides excellent training opportunities for staff. The service provides a consistent well-supervised staff team. The service is interested in the views of service users and their relatives, and keen to have ideas that will improve what they do. The service is managed in a manner that promotes the health, safety and welfare of service users, staff and others who use the building. What has improved since the last inspection? What they could do better: 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 DS0000067768.V325972.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Willow House DS0000067768.V325972.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Willow House makes sure that they find out about the needs of those who want to use the service before they offer accommodation, thereby ensuring they are confident that they can meet the service user’s needs. EVIDENCE: All the care files looked at contained copies of completed “Essential Lifestyle Plans”, these are the agency’s assessment document. The service users and/or their representatives had helped to complete these. There was also additional information in these assessments and in the care files that clearly demonstrated that input from district nurses, psychologists, speech and language therapists and others with information about the service user were also sought. Discussion with the manager, and the records confirmed that assessments were done and that the manager met the service user in their own home (and/or other venues) so that as full a picture of their needs as possible could be gained. Discussion and correspondence also verified that considerable time was spent supporting service users and their families in becoming familiar with the service. Willow House DS0000067768.V325972.R01.S.doc Version 5.2 Page 9 It was clear that they (service users) were encouraged to spend afternoons and evenings in the home, getting to know staff, other service users and the layout of the building before receiving overnight support. The relative who was interviewed stated that: ‘Staff have got to know her and all her care needs.’ Willow House DS0000067768.V325972.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service promotes and supports the independence of individual service users in relation to the choices they make and the lifestyle they wish to lead whilst staying at Willow House. EVIDENCE: All service user care plans that were looked at had been completed with the service user and/or their relative, and provided detailed information about how the needs of the service user were to be met, with the ultimate outcome aimed at promoting and maintaining independence during their stay at the home. The service users at Willow House have complex communication needs and individual communication guidelines and aids were in place to support their independence. Willow House DS0000067768.V325972.R01.S.doc Version 5.2 Page 11 The majority of information was provided by, the family, health and social care professionals and others with an established relationship with each person. Notes and updates confirmed that these assessments were developed over a period time and were reviewed and changed in response to the needs of the individuals. The contents of the assessments included information about all the practical aspects of the immediate and short- term, physical, communication, psychological and social support required. In addition the wishes and aspirations of service users were recorded when these were expressed or became known to the staff. Diary notes and daily records were written in a respectful manner and the contents demonstrated that staff were knowledgeable about the needs of service users and how these were to be met. It was also easy to see when steps were taken to remedy any problems that were having a negative effect on individuals. Staff discussion supported this documentation. Correspondence also indicated that care staff were involved when a review of care took place. Staff who were interviewed were aware of the service user plans and how to make sure that they were meeting the individual needs of service users. Each person was familiar with the process of ‘person centred planning’ and how to treat each person as an individual. Each also felt that as a short term facility the staff needed to develop a good relationship with the relatives and listen to what they said in relation to providing a service. Over the inspection period none of the service users could give a specific opinion about the service. Observation of their interaction with staff and the environment indicated that they were confident when approaching staff and could make their needs known to them. Staff interaction with the service users confirmed that service users were encouraged to be independent and to take responsibility for as much as they could such as sorting out their clothes, choosing meals and keeping the home tidy. Comments from those interviewed included: ‘They meet all care needs, I have every confidence.’ Willow House DS0000067768.V325972.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to maintain and develop their life skills. Effort is made to meet individual expectations in relation to recreation thus providing service users with opportunities to remain as part of the community. EVIDENCE: The daily records and reports confirmed that service users were supported in attending their regular day activities such as college or work. Care plans and assessments identified the interests of service users and included a description of what people wanted to do (and where able to do) for themselves. Daily reports and comments made by staff confirmed that service users were supported in completing domestic tasks such as washing up, making snacks and looking after their clothes. Willow House DS0000067768.V325972.R01.S.doc Version 5.2 Page 13 Staff and relatives interviewed stated that activities provided by the home included jigsaws, large format games such as ‘connect four’, dominoes, arts and crafts and other home based activities. Service users are also supported in going for walks, going to the cinema, going shopping and going to the pub when transport is available. The service is not within easy walking distance of the town and staff indicated that transport was not readily available which limits the services ability to promote community presence. However Willows House only provides respite and service users have ample opportunity to fully access the community through day services when with their main carers. Over the period of the inspection it was observed that service users appeared content to watch television and listen to music after a busy day. Staff were observed talking to and spending time with service users, providing encouragement and guidance in relation to what was happening during their stay. Daily reports and other correspondence confirmed that staff encouraged service users and supported them to take responsibility and control of their lives whenever possible. As a short term care establishment, the agency’s polices and procedure concerning personal relationships, suggests that, bearing in mind the ability of those involved, service users privacy would be maintained and appropriate support, guidance and access to advocacy would be sought as required. The service records food likes and dislikes for each service users. A record of food provided is also kept and indicated that a variety of homemade and convenience foods and take-aways, on occasion, was provided. During the course of the inspection service users were observed making a choice about their meals. The fridge , freezer and larder were well stocked with a variety of fresh and frozen foods including cheese, bacon, eggs, meat, fresh vegetables and fruit. Drinks included fruit juice, cordials, water, tea, coffee and hot chocolate. Training records confirmed that all staff had completed a Food Hygiene course. Comments made about the lifestyle provided by the home included: ‘They do a good job cooking wise- the staff here are brilliant- in summer they go for walks in the evening and play music.’ Willow House DS0000067768.V325972.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements in place ensures that health and personal care is based on the individuals’ needs and the principles of respect, dignity and privacy are put into practice. EVIDENCE: All the assessments and care plans looked at contained a detailed description of the health and personal care needs of service users. The emergency contact sheet also provided contact numbers for health care professionals such as the dietician, general practitioner and speech and language therapist. There were clear instructions, based on the needs of the individual, concerning the action that should be taken for a specific concern such as epilepsy or behaviours such as self-harm or mood swings. Specialist assessments and monitoring tools were in place including diet and fluid charts, body mapping for those who were prone to developing skin problems and behaviour monitoring charts. Willow House DS0000067768.V325972.R01.S.doc Version 5.2 Page 15 Daily records and discussion with staff and relatives confirmed that health concerns were dealt with in line with the care plans and that health care professionals and the relatives were kept informed of any changes. During the course of the inspection it was noted that staff had not received specialist training and instructions for working with service users with specific behaviour management needs. Due to this it was not possible to confirm that staff were working in a consistent manner and in keeping with the instruction provided by specialists. The manager, however, took action to remedy the situation as soon as it was noted. Correspondence also indicated that, the manager was an active member of any multidisciplinary meeting arranged to, discuss and assist with planning support with service users and their relatives. Records confirmed that staff training relating to in health care included, medication training, epilepsy awareness, autism awareness and sexual health. Over the course of the inspection it was observed that staff were friendly, relaxed and spontaneous when supporting service users, they were also observed to be respectful and treated people with dignity and patience. Discussions with staff confirmed that they knew the individual needs of service users Service users who access this respite facility do not manage their medication when at home. The medication policy was read through and the information provided staff with information about accepting, administering and recording medication. The storage system was examined and all medication was stored in locked areas and kept and administered from original containers or fully labelled blister packs provided by a pharmacist. Staff complete a medication record sheet when they have given the medication. Willow House DS0000067768.V325972.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service feel able to express any concerns and have access to a robust complaints procedure and protected by a robust adult protection policy. EVIDENCE: The complaints procedure and adult protection policies were read through. The complaints, compliments and comments procedure was clear and easy to follow. The adult protection procedure gave clear information about the actions that could be considered as abuse and provided information about recognising abuse and whistle blowing. The manager stated that no complaints had been recorded since the previous inspection. Relatives stated that they felt able to discuss any concerns comments included If I had a complaint I would come down and see them but the staff are brilliant.’ Staff training records confirmed that they had received adult protection training. Comments included ‘I’ve had PoVA training at induction and I went on a day course. If I saw anything I didn’t like I would talk to the manager.’ Willow House DS0000067768.V325972.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is excellent. This judgement was made using available evidence including a visit to the service. The physical design and layout of the home provides a safe, well-maintained and comfortable environment that encourages independence. EVIDENCE: Willow House short-term care unit is a new build unit and all equipment, furniture, fixtures and fittings are new and provided with the aim of meeting a range of needs, and encouraging independence and promoting safety.. A tour of the building was conducted. The rooms were clean and free from unpleasant odours. All furniture fixtures and fittings appeared domestic and homely, and all items were clean and pleasant to use. All the bedrooms have en-suite hand basin and toilet facilities and all areas have been fitted with track and hoist equipment. All toilet and shower and bathing areas were warm and ready to use. Willow House DS0000067768.V325972.R01.S.doc Version 5.2 Page 18 The hot water was checked and this maintained a comfortable temperature. A logbook is kept of the weekly temperature checks, this was examined and no problems were noted. The staff call system was checked and was in full working order. Service users were observed mobilising around the home freely. It was stated that service users were encouraged to bring personal items such as games, soft furnishings and other favourite items during their stay. Evidence of this was seen. Care files also identified that service users were given the opportunity to choose the same room whenever possible and if service users expressed a room preference this was noted. The communal area included a large lounge and separate dining area. The gardens were neat and accessed through French windows. The lounge is also fitted with a ‘loop’ system that will enhance the effectiveness of compatible hearing aids. The kitchen is equipped with small domestic appliances and it is possible for service users to prepare drinks and snacks. The washing machine is also small and domestic in size. Service users were observed accessing the kitchen safely. Willow House has been allocate domestic staff who carry out the majority of cleaning and domestic duties. These staff were interviewed and observed as they went about their duties and no problems were noted. The senior domestic has provided guidelines for care staff in relation to preventing cross infection. This includes which cloth and cleaning detergent is required for different cleaning jobs and how to dispose of cleaning materials. Although there were no concerns relating to the cleanliness of the building, domestic staff have not received updated health and safety training concerning storing fluids or prevention of cross infection and this would be of benefit. Files and other records confirmed that Oldham Health and Safety are beginning to monitor the service under the ‘Better Business Safer Food’ initiative. Willow House DS0000067768.V325972.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement was made using available evidence including a visit to the service. The service employs staff who are well trained and skilled and in sufficient numbers to support and meet the needs of the people who use the service. EVIDENCE: The recruitment and selection process is highly developed and is led by Oldham Metropolitan Borough Councils (OMBC) Human Resource department. This department adheres strictly to recruitment and selection guidelines concerning vetting new staff and completing all criminal record checks and verifying proof of identity and scrutinising the application forms and references for new recruits. The manager of Willow House is only able to roster new staff after HR have confirmed that the recruitment process is complete and all checks have been satisfactory. Willow House DS0000067768.V325972.R01.S.doc Version 5.2 Page 20 Induction training is provided through OMBC training unit and the programme includes: an introduction to learning disability; prevention of adult abuse, introduction to infection control; fire safety; moving and handling; an introduction into person centred planning and communication skills. Staff receive high quality training through the OMBC training partnership that provide in-house training but also commission colleges and specialist agencies to provide up-to-date training. The manager of Willow House stated that the majority of staff have now completed NVQ level 2 in care and more recent recruits have been put forward for the next intake. Training records provided by HR confirmed that staff training included: risk assessment management; Introduction and foundation courses in autism awareness; autism and sensory issues; introduction to dysphasia; Intensive Interaction; understanding anger and violence; objects of reference; using communication dictionaries, epilepsy awareness, completing life stories and Sexual health. The majority of staff have also undertaken, medication training, food hygiene training and a number have also completed NVQ level 3 in care. Daily reports and discussion with staff and relatives confirmed that staff are employed in sufficient numbers to meet the needs of service users during the busiest times of the day and night. The roster demonstrated that the ratio of staff rarely falls below three staff to four service users, and on occasion oneto-one and two-to-one support is provided. Those who were interviewed had no complaints about staffing in the home, with a relative commenting: ‘The staff are brilliant.’ Staff expressed a high level of satisfaction with the training and support provided commenting that the service provided was ‘like a family, very rewarding, staff worked as a team and rosters were managed so that staff could keep in touch service users’ and ‘I can’t fault OMBC for training- and we’re encouraged to put forwards our ideas.’ Staff were observed to have positive relationships with service users, visitors and each other. Willow House DS0000067768.V325972.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is suitably skilled and experienced in managing the service and implements the required procedures to ensure that service users needs are met, and that opportunities for service users and others to influence how the service operates are provided. EVIDENCE: The manager of the home has completed the NVQ level 4 registered manager award and she has completed health and safety training and the NVQ level 3 assessors award. Willow House DS0000067768.V325972.R01.S.doc Version 5.2 Page 22 Discussion with the manager indicates that she has a clear idea of the ethos and way in which the service should be run and the actions she must take to achieve this. Staff and relatives were complimentary about the way in which the service is run and the leadership offered by the manager. Service users are supported in completing a quality assessment following each stay at Willow House allowing them to provide a view on the service they have received and what (if anything) they would like done differently. A service quality assessment has also been undertaken involving service users and their representatives. The results and outcomes of this consultation were read through and demonstrated that Willow House used the information to influence the running of the organisation in the following areas food, the environment, resources, activities and staffing. The manager takes her responsibilities for managing the building and health and safety protocols seriously and is competent. It was clear through maintenance records and discussions that equipment and services had been recently installed or serviced. A fire safety inspection had been completed and all recommendations had been complied with. The fire safety logbook was examined and this was up to date, with evidence that all checks had been undertaken regularly. The manager is in the process of putting together a manual of the most relevant policies and procedure developed by OMBC. The aim of this is to provide staff with a more accessible and compact manual of the policies and procedures most relevant to the work they do. The manager has always co-operated with the CSCI inspection and registration processes. This area could be improved if the quality assurance report were presented in different formats so that it was accessible to people with different communication needs. Willow House DS0000067768.V325972.R01.S.doc Version 5.2 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 Standard No Score 1 X 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 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 x 32 4 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 x 3 x x 3 x Willow House DS0000067768.V325972.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 YA39 Good Practice Recommendations The manager should consider developing care plans and other documents (such as the feed back from their quality assurance monitoring) in different formats to meet the different communication skills of service users. This will enable people (of differing abilities) to contribute and influence the service provided. The manager should make sure that staff receive training to deal with all complex needs that have been identified at multidisciplinary reviews, and for which care plans have been developed. This will further improve the development of staff to meet needs. The manager should ensure that she is aware of the fees payable in order that she may pass accurate information onto service users and/or their representatives. 2 YA3 3 YA1 Willow House DS0000067768.V325972.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 DS0000067768.V325972.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!