Inspection on 21/12/07 for Willow Lodge

This inspection was carried out on 21st December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Willow Lodge 05/05/10

Willow Lodge 18/02/10

Willow Lodge 17/11/09

Willow Lodge 11/12/08

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Willow Lodge 11-15 Stein Road Emsworth Hampshire PO10 8LB Lead Inspector Kathryn Kirk Key Unannounced Inspection 21st December 2007 09:00 X10015.doc Version 1.40 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 Lodge DS0000069939.V353635.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 Older People. 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 Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow Lodge Address 11-15 Stein Road Emsworth Hampshire PO10 8LB 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) 01329 836281 01329 836287 andrew.geach@willow-lodge.co.uk Mr Andrew Robert Geach Mr Stephen Richard Geach Mrs Christine Anne Jarrett Care Home 26 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 26. Date of last inspection N/A Brief Description of the Service: Willow Lodge is registered to support and accommodate up to 26 older people any one of whom could have a diagnosis of dementia. The home is in the residential area of Southbourne, close to Emsworth. There are 14 single bedrooms and six double rooms, over three floors. The majority of the rooms have en-suite facilities, although most of en-suite baths are not currently in use. There is one communal bathroom with an adapted bath on the second floor. The home has a large open plan dining room / lounge which opens out onto a large patio area and secure rear garden. Current fees range between £335-£450 per week. Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection for this service. Information for this report was gained in the following ways: The manager completed an annual quality assurance assessment, which provided a lot of information about how the service is running. Surveys, giving the views of four staff members and eight service users and their relatives were completed. Two health and social care professionals also provided information over the telephone. Written information gathered during and following the registration process was reviewed A visit to the service took place on 21 December 2007. This lasted for 8 hours. During this time we looked around both the communal areas and the private bedrooms , spoke with the manager, four staff, three visitors and ten service users. Staff interactions with service users were observed. Some of the services paperwork was also reviewed. The provider was present at the end of the inspection and the findings were discussed with him and the manager. What the service does well: The manager has recently introduced a keyworking system. This is where each staff member has particular responsibilities for a small group of service users, for example, ensuring that their clothes are kept tidy and that they have appropriate toiletries. People are very complimentary about the food. There is a lot of home baking. People are consulted about what they like to eat and are given plenty of choice. There has been a lot of work done to make the environment safer, for example by replacing the fire alarm system. The home is also better to live in, because a number of cosmetic improvements have been made, for example, there are a number of new carpets and some communal and private areas have been redecorated. Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 6 People feel that staff care. Comments such as “staff are lovely” and “staff show genuine concern for the wellbeing of residents” were representative of those received. What has improved since the last inspection? What they could do better: The service users guide needs to be updated and needs to be available to all people who are considering moving to Willow Lodge or who are currently living there. This will help to give more information about what the service can provide The process of reviewing care plans needs to continue to ensure that they contain information that helps staff to provide appropriate care and support. Service users and/or their representatives should be involved in this process as much as is practicable. Further work is this is needed, particularly where a risk, for example of falling, has been identified, to guide staff and to ensure people are as safe as possible. Lockable storage must be supplied to all for the safe storage of medicines if required, and/or for valuables. Current medication procedures must be reviewed and additional training supplied to staff as necessary to ensure that medicines are safely handled within the home. Bathing arrangements need to be improved by ensuring that people are able to use the en suite baths in their rooms. Radiators and hot water pipes need to be covered to prevent the risk of scalding. This work is in the process of being completed and will be finished by the end of January 2008. Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 7 Staff files all need to contain two written references. This helps to ensure that the recruitment procedure is robust. The service needs to notify The Commission for Social Care Inspection of all significant events that occur and any action that is taken as a result. This helps us to evaluate how effective the home is being in meeting National Minimum Standards and Care Home Regulations. 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 Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Standard 6 does not apply Quality in this outcome area is adequate The information gathered before people move to the home helps to ensure that their needs will be met once they are admitted. The Service User guide needs updating to ensure that people are properly informed about what the home can provide. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The annual quality assurance assessment, says that the service provides information to service users through their statement of purpose and service users guide. It says that people are encouraged to visit home and that a pre admission assessment is completed. This is where prospective residents are visited to assess and discuss their present care needs. It says that all service Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 10 users have trial period. This is to enable the person to see if the service provided is as wished. It says that the same information is collected for emergency admissions. During the visit to the service one visitor confirmed that they had looked around the home on behalf of their relative before a decision to move in had been taken. Two files of recently admitted service users were seen. They contained evidence that information about the persons’ medical, care and social needs. This had been obtained before they moved in. There was also information on file from peoples previous placement and/or from health and social care professionals. The service users guide was seen. It contained information, which is now out of date. The manager was aware of this and is working to ensure that it is accurate. Once this process has been completed the up to date guide will be available to prospective and current service users and their families. This will help to give them further information about what the service has to offer and so will also assist in the process of helping in their choice of home. Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Quality in this outcome area is adequate Peoples’ health and care needs are known. Some care plans need to contain more guidance for staff, particularly in areas where a risk to an individuals wellbeing has been established . Current medication processes need to improve to ensure that people are not put at unnecessary risk This judgement has been made using available evidence including a visit to this service. EVIDENCE: The annual quality assessment says that care plans are reviewed monthly and that ”We generate comprehensive care plans from the discussed assessment of needs” The aims include “to further develop care plans in alternative format to promote understanding from those with lesser communication skills” Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 12 Three service users files were seen during the visit. These files included care plans. The information about peoples needs had been regularly reviewed, although not always every month. There was however, evidence that changes in need had been recorded, for example when one person had expressed a preference to be attended to by same sex carers, this had been recorded on their care plan. The files and associated documents, for example, daily diary, contained a lot of information about the needs of service users. Risk, for example, of falls, were assessed, although for one person who came out as a high risk of falling, there was no guidance for staff as to how this could be minimised. One care plan said “needs toileting regularly” It did not provide any further information to staff. Care plans included information about what people could do, as well as what they needed help with. This is important because it ensures that people preserve their skills for as long as possible. One service user said that they had not seen their care plan and would like to. One staff member spoken with said that the new keyworker system would help staff to spend more time with service users and would help to ensure that their needs were understood and met. Staff surveys reflected that they felt that they were given up to date information about the people they care for although one person said that sometimes “better communication between staff” was needed During the visit to the service the manager and senior staff confirmed that they are in the process of changing care plans to a format that is better for service users and for staff. As this work is already in process no requirement has been made regarding care planning systems within the home. There was evidence through discussion with staff and through records, that health needs were being regularly monitored, for example for one service user whose medication was being changed, records reflected that staff were monitoring any changes in response to the request by the GP. Records also showed that staff had been vigilant in ensuring that the specialist mattress supplied for one service user was replaced within a day when it developed a fault. One visiting health care professional said that any issues that arise are discussed with staff at the time. Three visitors spoken with felt that their relatives health and care needs were managed well by staff and one person said that their mother had improved in her health since she had been in the home. Medicines were observed to be securely stored. The manager said that no service users currently administer their own medication although one person had wanted to. She said that this had not been possible because there was no lockable storage available for them. The handling of medicines was discussed with staff and some records were seen. The following was found; Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 13 Staff had not administered prescribed medicines to two service users on two occasions. When the error was discovered, it was unclear what, if any, action staff had taken. Procedures to guide staff in this were not readily available. One service user had had one medication changed on the administration sheet from “regular” to “as required” There was no indication of who had approved this change either in the persons records or on the medical administration sheet. The manager said that she was aware that the medication administration sheets had not always been correctly filled in and had already arranged a meeting with staff to discuss this. Staff spoken with confirmed that all those handling medicines have received training in this area. The proprietor said that he would support staff to go on any further training that may be needed. Staff were observed to talk with service users in a friendly and respectful way. One service user spoken with had their own telephone. The manager said that one person has a key to their room, all others do not wish to keep one. Screening was seen in shared rooms and the manager said that people or their relatives were consulted before any sharing arrangement is started. Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. People are provided with suitable activities to match their interests and preferences. The food is very good This judgement has been made using available evidence including a visit to this service. EVIDENCE: The annual quality assurance assessment says that the service has taken on a new activity co ordinator to maintain a programme of events for service users on a daily basis. It also states that reminiscence and other therapeutic activities are offered by an external provider who visits the home. The manager said that residents can go to church if this is their wish and that religious services are held within the home. A Christmas party had been held the day before the visit to the home. Service users spoken with about this said that it had been much enjoyed. One visitor said “they try very hard and stimulate the residents with quizzes, singing games etc.” Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 15 Visitors spoken with said that they were always made welcome and service users said that they could see their relatives in private if they wanted to. The manager said that service users are encouraged to manage their own financial affairs for as long as they wish and are able to. The lack of lockable storage space observed in some of the bedrooms means that people do not always have a secure place in which to store their valuables. People were very positive about the food provided within the home. One visitor for example described the food as excellent and service users said “the cook is marvellous” food is “spot on” Food seen on the day of the visit was freshly cooked attractively presented and offered service users plenty of choice. Staff were seen to check with service users how they had enjoyed their meal and were observed during mealtimes to be very attentive to peoples needs, whether they needed help to eat or whether they needed condiments or extra drinks. Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good The services procedures ensure that people can make complaints if they wish to. They also help to protect them from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People asked knew how to make a complaint. Most people said that they felt comfortable about making suggestions or complaints. Visitors commented “they hold regular meetings to voice any complaints or ways to improve the service” and “staff dealt promptly with any concerns” All staff surveyed and those spoken with said that they would know what to do if anyone had concerns about the home. A record of complaints made is kept. This was seen and it was evident that staff had taken action where this was required. The annual quality assurance assessment says that “staff undertake regular training about safeguarding of vulnerable persons and have access to policies and procedures at all times” one staff member spoken with had not yet had this training but was able to describe what action she would take if they witnessed or were told about an abusive act. A list of training seen included a Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 17 course on protection of vulnerable adults and managing challenging behaviour although the date for this was yet to be arranged. There was written evidence that staff had followed procedures appropriately when there had been a safeguarding issue. Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21 24,and 26 Quality in this outcome area is adequate. There have been significant improvements made to the environment although more are still needed –bathing arrangements in particular are still not satisfactory. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of the registration process, the service submitted an action plan which detailed the intended improvements to be made to the environment. Areas needing attention were: Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 19 1)The fire alarm system needed to be replaced. 2)The cooker needed to be replaced 3)Upstairs windows needed to be restricted. 4)The patio area needed to be made safe 5)Several radiators and hot water pipes needed to be covered 6)The baths in en suite facilities were not in use and needed thermostatic valves fitted. 7) Many areas needed recarpetting and redecorating. At the time of this inspection the evidence of progress (gathered from the annual quality assurance assessment, through talking with the manager and proprietor and by touring the building) was as follows: 1) –4) had been completed. Some radiators had been covered but not all. The manager said that this would be completed by the end of January 2008 Most En suite baths were still not in use. This meant that service users still had to use the one adapted bathroom on the second floor. Some bedrooms and communal areas have new carpets and decorations. New furniture has been supplied in some bedrooms. New laundry equipment has been purchased. The proprietor said that the improvements had taken longer than initially anticipated and expressed a commitment to completing the work that is still outstanding. Service users, their visitors and visiting professionals all said that the home was always clean and tidy. A recent report from the environmental health officer was seen. This did not make any requirements. The manager said that the sluice steriliser has recently been serviced . Paper towels and liquid soap were seen in communal washing areas. Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 20 Hand cleaning solution is available for all in corridors to help to control the risk of spread of infection Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good Service users are supported by sufficient numbers of staff, who are offered a good range of training. Some additional training may be needed in the management of medicines. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the visit twenty four service users were living at Willow Lodge. Five care staff were on duty in the morning and three care staff were on duty in the afternoon. The manager and deputy were also working. There are two waking care staff on duty each night. A cook is employed every day, domestic staff help in the kitchen, and there is a cleaner 5 days a week. The manager said that there was no designated laundry assistant at present but said that she plans to change this. A handyman is employed and is shared with another home. Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 22 Staff spoken with said that they had enough time to complete their duties, this was largely echoed in the staff surveys. All staff felt that they had the right support, experience and knowledge to meet the different needs of people. Relatives and service users spoken with were also in general agreement with this. “Service users and relatives spoke highly of the staff team. Representative comments were “Staff are lovely” “staff are polite attentive and always treat residents with respect and dignity” “staff show genuine concern for wellbeing of residents” Records show that of the eighteen care staff currently employed , eight have obtained at least an National Vocational Qualification in Care level 2 or equivalent and three are working towards this. All four staff surveyed said that proper recruitment checks had been carried out on them before they were employed at Willow Lodge and staff spoken with also agreed that this was the case. Two records were checked of recently employed staff members. There was evidence that both had applied for CRB checks. One person had not yet had their full CRB disclosure returned but had completed an initial check They were working, but under supervision. This is in line with current guidance. Both staff had completed application forms and a health declaration. One file contained two written references and the other had one. The manager said that she had received a verbal reference, although there was nothing written on the file to reflect this. The manager said that she is chasing up the other written reference for this staff member. All staff spoken with and surveyed said that their induction training covered very well everything that they needed to know when they started the job. The manager said that staff induction training has been altered to promote a greater awareness of equality and diversity. Staff spoken with, and some records seen, show that staff have had some training in dementia care. The manager and deputy have completed an intensive course , other staff at present have only had a short session. The manager said that further training in this will be available and four other staff are going to attend a 22 week course in the subject. There was also evidence that staff are given training which includes: moving and handling, fire safety, infection control, food hygiene and first aid. As discussed in a previous section, staff who handle medicines have all had training to do so, although there was evidence that some practices were not satisfactory in this area. Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 23 It was difficult to establish whether all staff had attended key health and safety training or when training is needing to be updated. The manager said that a training co-ordinator is being employed to oversee this. Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. There is a clear management structure within the home but some key areas of health and safety, particularly in regard to the management of medicines need to be developed further to ensure the safety of service users This judgement has been made using available evidence including a visit to this service. EVIDENCE: Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 25 The registered manager is Mrs Christine Jarrett. She has 18 years of experience in care and eight years in management. There is written evidence that within the past twelve months she has undertaken training which includes dementia care, the mental capacity act and adult protection. This shows that she continues to update her knowledge and skills. It was clear through discussion that she has a clear vision of how the service should develop. The annual quality assurance assessment states that the quality of the service is monitored in the following ways: Regular staff and residents meetings Care reviews Home safety checks and health and safety risk assessments Annual environmental health inspections Equipment safety checks There was written evidence that within the last three months, the manager had conducted a survey of relatives to find out their views of the home. The manager has informed us of some significant events that have occurred in the home. This is required under Regulation 37 of the Care Homes Regulations 2001. During the visit, it was established that we have not however, received notification of all significant events. An example would be the medication error that has been discussed in previous sections. It is important that this information is provided, as it tells us what action the home has taken and is further evidence of how the service is performing within the context of National Minimum Standards and Care Home Regulations. Records seen showed that the owner carries out a monthly visit and prepares a written report as to the conduct of the care home. The proprietor said that this would be carried out by an independent consultant in future. The manager confirmed that the service does not act as appointees for service users money. Any small amounts of money held on behalf of service users is securely stored and all transactions are recorded. The annual quality assurance assessment confirms that all equipment in the home has been serviced or tested as recommended by the manufacturer or other regulatory body. It also confirms all that policies and procedures have been reviewed within the last twelve months. Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 26 Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 1 X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 28 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. 1 Standard OP9 Regulation 13(2) Requirement All staff who administer medication must receive further guidance and training if necessary to ensure that they are all doing so safely Medication must be administered as prescribed and clear records must be kept of any authorised changes to medication. Bathing facilities must be improved by installing thermostatic controls to en suite baths. Suitable lockable storage must be provided. Timescale for action 31/01/08 2 OP21 23(2)(j) 31/03/08 3 OP24 23(2)(m) 28/02/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 29 Willow Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Lodge DS0000069939.V353635.R01.S.doc Version 5.2 Page 31 - 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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