Inspection on 18/10/05 for Willow Tree Nursing Home

This inspection was carried out on 18th October 2005.

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

Other inspections for this house

Willow Tree Nursing Home 11/08/09

Willow Tree Nursing Home 11/08/08

Willow Tree Nursing Home 12/09/07

Willow Tree Nursing Home 09/10/06

Willow Tree Nursing Home 20/06/05

Willow Tree Nursing Home 10/11/04

Willow Tree Nursing Home 06/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Willow Tree Nursing Home 12 School Street Hillmorton Rugby Warwickshire CV21 4BW Lead Inspector Mrs Suzette Farrelly Unannounced Inspection 18th October 2005 11:00 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 Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 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 Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Willow Tree Nursing Home Address 12 School Street Hillmorton Rugby Warwickshire CV21 4BW 01788 574689 01788 551791 carolmatron@yahoo.co.uk 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) Culpepper Care Limited Carol Anne McCullough Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th June 2005 Brief Description of the Service: Willow Tree Nursing Home is registered to provide personal and nursing care for up to 34 service users in the category of old age. Willow Tree is a single storey establishment converted from a domestic bungalow and extended to include single and shared accommodation and is situated in a local suburb of Rugby approximately 3 miles from the town centre. Willow Tree is close to local shops and a bus route. There are two lounges and two dining rooms in the home. The communal areas of the home are situated at each end with bedroom accommodation integrated between them. All service user accommodation has an open outlook either onto the large garden or the inner courtyard. The home is staffed by a complement of qualified nursing staff and care assistants. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second inspection of 2005/06 and this report should be read with the previous report from the inspection conducted on 20th June 2005. The inspection commenced at 11:00 and was concluded at 18:00. A full tour of the premises was made and records related to employment and training of staff were examined. Five residents were spoken to and one relative. The GP while visiting also discussed her views of the service. Records related to the residents were seen. Three staff and the manager were interviewed. On arrival the inspector was informed by a resident that they had just finished a singing along to ‘old time music’ and that this was really good fun. What the service does well: The interaction between the staff, residents and relatives is very good. One relative stated that the home was excellent and that the staff communicate changes in the resident’s well being regularly and supported the relative in visiting and spending time with the resident. Activities and meeting the interests of the residents is evident and those residents spoken to said that they enjoyed outings and activities in the home such as singing, exercise, reading newspapers and being assisted to visit relatives and go to community centres. The management of health care needs are very good, one resident’s pressure damage, which was acquired while in hospital, has healed. The GP also stated that the home is very good at carrying out her instructions and ensuring that the health needs of the residents are met. The surrounding grounds are well managed and accessible to all the residents, some families have brought garden ornaments and plants that have been situated so that they can be viewed by their relative from the individual bedroom windows. The residents reported that the food served is very good and that all meals are home made. Residents are asked in the morning what they would like for their main meal, one resident stated that she has often requested a different meal and this is supplied, staff confirmed this. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Some bedrooms were noted to have an unpleasant odour. The manager must consider how this can be managed. The fridge in the kitchen area has a broken seal, this must be replaced or a new fridge purchased. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 7 The manager must ensure that staff do not leave cleaning chemicals in residents rooms, all chemicals must be locked away when not in use. The manager and qualified staff must ensure that the records related to ordering, administration and disposal of medication are completed and maintained up to date. The manager must work with the qualified staff to ensure that the residents’ records and care plans are appropriate and demonstrate the care that is being delivered. Evaluation of care must be evident in the care profiles. The manager must ensure that record keeping in the home is up to date and appropriate. Storage of records must be secure. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 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 Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 4, and 5 were assessed Prospective residents are given sufficient information to assist them in choosing where they live. Prospective residents and their families are given the opportunity to visit before admission to the home, and are informed prior to admission that the home can meet their needs increasing their confidence that they will be cared for. EVIDENCE: The Statement of Purpose and Residents’ Guide are available in the reception area. All prospective residents and their families are given a copy of the Residents’ Guide prior to admission to ensure that they are aware of the services available within the home. During discussion the manager stated that these documents have been evaluated and are being up dated to ensure that the information concerning staff and the environment are up dated. It was confirmed through records, observation and discussion with staff, residents and relatives that the home is able to meet the needs of the residents who live at the home. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 10 Records and discussion with the manager and staff confirmed that recent training in Dementia Care, Parkinsonism, Diabetes and Infection Control have been attended by most staff. One relative spoken to stated that the home have meet the needs of her relative who lives at the home, and that she was very pleased with the care given. Three residents spoken to stated that their families had chosen the home prior to admission, but that they were satisfied with the care that they received and were satisfied with their daily life. One resident had booked a room with the home while living in the near by bungalows. All residents have a three-month settling in period before a permanent placement is agreed. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All standards in this section were assessed. The residents health care needs are full met, however, the health, personal and social care needs are poorly set out in individual care plans which may result in an oversight of care and poor audit trails of care. The residents are not fully protected by the practices of recording and administering medication; this may result in harm to a resident. Residents feel they are treated with dignity and that their privacy is respected and maintained. Residents and relatives are assured that at the time of death they will be treated with sensitivity and respect. EVIDENCE: Three resident care profiles were fully examined and it was noted that the care plans did not clearly state the care that was to be given. The evaluation of care was not consistently carried out monthly and there was little evidence that residents’ or relatives were consulted during the process. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 12 The manager stated that she was aware of this and that training and discussion in meetings to address this issue was planned. In one profile there was an example of a very good care plan for a resident with an infection. This was also discussed and the manager stated that she had completed this profile and intended using this as an example for the care planning process. A variety of risk assessments are conducted by staff covering pressure damage, nutrition, and mental health, and there was evidence that other professionals were consulted such as the speech and language therapist and dietician. There was no evidence of preventative care plans and this could result in deterioration of health in the resident. During the inspection the home’s GP visited and discussed her relationship with the home stating that the care given was very good and she felt confident that the home was capable of dealing with the variety of health needs of the residents’ under her care. Residents’ have the opportunity to be seen by the ophthalmologist, dentist, chiropodist and hearing specialist. Clear records of out patient visits and consultations were available. The staff record medication received when a resident is admitted or returns from hospital. It was noticed that abbreviations were used for the route and quantity of medication to be administered and this is poor practice. The administration records were also not maintained and gaps were evident making it difficult to determine if the resident had been given their medication as prescribed. The medication is stored appropriately and records of incoming and medication disposed of are fine. From observation, records and discussion with residents and a relative it was found that the residents feel that their dignity and privacy is respected at all times. Residents have access to a public phone and some have private phones in their rooms. One resident has a mobile phone and the manager stated that a number of relatives bring in mobile phones and residents use these to contact loved ones. All residents appeared well groomed and dressed in clean clothes. One resident spoken to stated that she was very pleased with the laundering of her clothes and the attitude of staff when they assisted with personal care. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 13 Screening is available in all shared rooms, one resident in a shared room said that they had a good relationship with the person they shared with and enjoyed the company. During the inspection a relative stated that her relative had been very ill and that she was delighted with the care given by the home and that she had been consulted at all times about the ongoing care given. When asked about visiting she stated that she spent every day at the home and that the staff gave her meals and regular drinks, discussed care and always made her welcome. From discussion with the manager it was confirmed that the home will continue to care for residents for as long as they are able and use the support of the local McMillan Nurses and the some staff have also attended the Foundation in Palliative Care training. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All standards in this section were assessed The residents find that the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs increasing the positive outcomes of living at the home. Residents are assisted by the home to maintain contact with family and friends maintaining their experience of socialisation and belonging to family groups. Residents are assisted to make choices where possible therefore maintaining their independence. Residents are offered the choice of wholesome and appealing meals that are well balance and dine in pleasant surroundings increasing the socialisation of eating. EVIDENCE: The home offers residents a variety of activities that suit their individual needs. Two residents spoken to state that they are assisted to go out shopping, attend community centres and church. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 15 In the home the staff are encouraged to conduct a variety of activities and other entertainment is purchased from outside the home. One day a week a physiotherapy session is carried out and some residents attend these regularly. On the day of the inspection a session of old time singing was carried out in the morning, residents in the lounge were discussing this. Later in the afternoon a member of staff did exercise to music and encouraged residents to move to music using a small ball. The home does not have a standard activity programme and it was noted that individual activities are not regularly recorded in the individual records. There are no restrictions on visiting, this is stated in the Residents’ Guide and a relative confirmed this. Two residents stated that they are assisted to go home to family for special occasions and if requested by the family or resident. The manager discusses with relatives and friends their role in maintaining involvement with the resident after admission. One relative and two residents stated that they were aware of what they could be involved in and said that they could discuss areas that they wish to be involved in with the manager. Residents, who are able, manage their own affairs. One resident stated that with assistance from family she manages her own finances and the selling of her property. Other residents are assisted by family to manage their financial affairs. One resident without family is represented by Advocacy Alliance. The home does not manage residents’ affairs at any time. The home has a four-week menu that clearly states the main meal of the day and teatime. There is no evidence of a choice for each day, however, residents spoken to stated that they can request a different meal if they wish. Residents and one relative stated that the food is very nice, tasty and enjoyable and that all food is home made. One resident stated that the ‘puddings are delicious’. Records seen indicated that residents weights are maintained and those who were admitted with a below average weight have gained weight. Meals are served in two dining areas one is directly attached to a lounge area and the second in attached to the kitchen. The residents are discreetly assisted to eat their meals and it was noted that there was a relaxed and pleasant atmosphere. The kitchen was inspected and found to be clean and well organised, there was a sufficient supply of food and fresh produce was in evidence. Schedules for maintaining cleanliness and fridge/freezer temperatures were up to date. One of the fridges has a torn seal, this may affect the temperature and must be repair or a new fridge purchased. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All standards in this section were assessed. Residents, their relatives and friends are confident that their complaints and concerns are listened to, taken seriously and acted upon, maintaining their confidence in the service. Residents’ legal rights are protected and they are protected from abuse by the homes policies and procedures and training of staff. EVIDENCE: The home has had no complaints for over a year, residents and relatives spoken to stated that the home responded quickly to any concerns raised. These are not recorded by the home and it is recommended that this be commenced. The policies and procedures related to complaints are in the process of being up dated. These will be fully assessed at the next inspection. Three residents stated that they had voted at the last election and were following recent changes in the political process. The manager confirmed that those residents who wished to could use postal votes or visit the polling station. The manager and deputy manager have recently attended ‘Abuse Training for Managers’ and have organised further training for the care staff to ensure that all staff are aware of their individual responsibilities in protecting vulnerable adults. The policies and procedures have been reviewed and are in line with national and local policies for dealing with actual and suspected abuse. The Whistle Blowing policy is also appropriate. The home also has organised training in the management of verbal and aggressive behaviour and a suitable policy and procedure was seen. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All standards in this section were assessed The residents live in a safe, well-maintained environment that is comfortable with indoor and outdoor communal facilities that increase the positive outcomes for the residents. The residents have safe and comfortable bedrooms with their own possessions around them that meets their needs and maintains individuality and positive outcomes. The majority of the home is clean, pleasant and hygienic; some bedrooms have unpleasant smells, which may impact on the outcome for the residents occupying these rooms. EVIDENCE: During the tour of the home it was noted that all the corridors and communal areas have been redecorated in bright cheerful colours that assist the residents to know where they are. Most bedrooms have now been redecorated and the manager stated that the residents were consulted concerning the colour they would prefer two residents confirmed this. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 18 Two of the three bathrooms have been refurbished, one containing an assisted bath with over-head shower and the other with a walk-in shower. Both rooms are cheerful and bright and inviting ensuring that the experience of personal hygiene is pleasant. The two lounge areas are tastefully decorated and there is a good selection of seating to suit the needs of the residents. All windows from the lounge areas look out onto the garden areas and the residents can get into the garden through patio doors from these areas. The bedrooms all look onto the gardens or the courtyard and resident families have also brought items for the garden such as potted plants and garden ornaments and these are situated so that the resident can see them from their own rooms. It was noted during the tour that the bedrooms contain items belonging to the resident, some have picture, item of sentimental value and other rooms contain furniture belonging to the resident. The manager encourages the residents to organise their own space and supports the residents to enjoy this space. One resident stated that she enjoys making her own bed and tidying her room. There are some adjustable beds these are used for residents with varying abilities. The home has a variety of equipment to assist with the moving and handling of residents. During the tour staff were seen assisting residents to transfer to chairs using a lifting belt. All bathrooms and toilets have a variety of handrails to assist residents to stand and transfer. The home has three standing hoists, one full hoist and slide sheets. A new boiler system has been put into place and the central heating system has been up dated. Each radiator can be individually controlled and they are low surface reducing the risk of scalding. The maintenance person checks the hot water outlet temperatures monthly and these are recorded; where the outlet temperatures are too high the thermostatic mixing valves are adjusted. The laundry is suitably situated and well managed. It was noted that there was no hand soap or paper towels, the laundry person replaced these during the inspection. Infection control was discussed with the laundry person and the manager and since the training in infection control the home is to implement the use of specialist bags for soiled and dirty laundry. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All the standards in this section were assessed. The residents’ needs are met by an appropriate numbers and skill mix of staff that are suitably trained ensuring the safety of the residents. The residents’ are supported and protected by the home’s recruitment policies and practices ensuring that the residents are treated with respect and care. EVIDENCE: The home has increased the number of staff to carry out domestic duties in the home, and there are sufficient staff to carryout the cooking and care of the kitchen. There are adequate staff on duty throughout the day and night to meet the needs of the residents. The home has recently employed further staff and the use of agency care staff has reduced significantly. More qualified staff have also been employed since the last inspection allowing the manager to spend more time in management enabling a number of areas to be addressed. From discussion and examination of records it was established that over 50 of the staff are qualified to National Vocational Qualification level II or above. Three records of recently employed staff were examined; these confirmed that the management are now following robust employment procedures including a full criminal record check and protection of vulnerable adult list check. One new member of staff is a qualified nurse from abroad, work permits were appropriate and all checks needed were carried out. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 20 The home has recently signed up with the Workforce Development Partnership in Warwickshire ensuring that the new induction programme will be implemented and funding will continue to be available for NVQ training. The home has an up to date list of all staff training and this was examined and it was noted that staff have attended a variety of training associated with their own particular role. One housekeeper has completed an NVQ level II in housekeeping and care staff have attended training in infection control, dementia, diabetes and Parkinsonism. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36 and 37 were fully assessed, and 38 was partly assessed. The residents 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 her responsibilities fully and ensure that the home is run to the best interest of the residents. The residents’ financial interests are safeguarded and their rights and best interests are safeguarded by the homes policies and procedures ensuring that their rights are met and best outcomes are achieved. The home’s recordkeeping in relation to residents’ is inadequate and may result in omissions in provisions of care. Staff are mostly supervised ensuring that there is consistency of care and work processes increasing the positive outcomes for the residents. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 22 EVIDENCE: The present manager has managed the home for 3 years and previously worked as the deputy manager. She has completed her NVQ level IV in Care Management and is completing the Registered Managers Award. The manager has joined the Care Managers Council and receives up to date information on care and management and attends meetings. She also up dates her knowledge through newsletters, journals and attending courses. The home is continuing to develop the quality assurance and monitoring systems, surveying of relatives has been implemented and the manager has analysed these. Also an audit of falls and accidents is conducted monthly and a domestic audit is carried out. The home is going to commence further audits to ensure that all systems in the home function to the minimum level and to look at ways that improvements can be made. This standard is to be more fully assessed at the next inspection. The home manages a small amount of residents’ personal monies, these are maintained in a safe place and each resident’s money is kept separate. Records of incoming and outgoing monies with receipts are maintained. There is also a suitable policy and procedure for handling personal items and lost property. Staff supervision was discussed and the files were examined. Staff generally receive supervision every two months, it was noted that there are some staff that have not received supervision as often as required. Records in the home are kept is a variety of places. The manager must ensure that personal inform related to residents is not available for public viewing. Staff records are securely locked away. The manager must also ensure that the residents’ records are kept up to date and all information required is recorded and maintained. Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 23 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 3 X X 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 3 3 2 2 X Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 2. OP7 15 The registered manager must 31/08/05 ensure that care plans are current and set out in detail each service users health, personal and social care needs. Care plans should be reviewed monthly. (Old timescale of 31/01/05 and 20/06/05 not met.) The registered manager must ensure that there are suitable preventative care plans developed where a risk to health is recognised from risk assessments carried out. The registered manager must ensure that accurate records are maintained of medications administered. Records must include dosage and frequency of administration. Any changes to medications must be dated and signed. (Old timeframe of immediate not met) 31/12/05 3. OP8 15, 17, 3 4. OP9 13 30/11/05 Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 25 5 OP15 16(2)(g) The registered manager must ensure that the seal on the fridge in the kitchen is either replaced or a new fridge is purchased. The registered manager must ensure that all bedrooms are free from offensive odours. The registered manager must ensure that a full quality assurance and monitoring system is put into place to monitor the service provided and to demonstrate improvements. The responsible individual must complete a report of monthly Regulation 26 visits and forward a copy to the Commission for Social Care Inspection. (Old timescale of immediate from previous inspection Nov 2004 is not met) 30/11/05 6 OP24 16(2)(k) 31/12/05 7 OP33 24 31/12/05 8 OP36 18(2) The registered manager must ensure that all care staff receive supervision six times a year. The registered manager must ensure that personal information related to residents is not accessible to other than staff, the residents’ representatives and other professionals. 30/11/05 9 OP37 26, 17 31/07/05 Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 26 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 OP7 Good Practice Recommendations The inspector recommends that the manager develop the falls risk assessment in accordance with good practice guidelines e.g. The National Institute of Clinical Excellence. (NICE) The inspector recommends that tissue viability policy is reviewed in accordance with clinical guidelines and local PCT wound formulary. It is recommended that the home develop a menu that indicates what is for breakfast and offers a choice on a daily basis. It is recommended that the manager records concerns voiced by staff, residents and their relatives with actions taken as part of the complaints process. 2. OP8 3. OP15 4. OP16 Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Willow Tree Nursing Home DS0000004415.V260016.R01.S.doc Version 5.0 Page 28 - 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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