Inspection on 03/05/07 for Willowmead

This inspection was carried out on 3rd May 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

Willowmead 07/11/05

Willowmead 17/06/05

Willowmead 10/01/05

Willowmead 30/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

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 Willowmead Willowmead Summer Road East Molesey Surrey KT8 9LR Lead Inspector Susan McBriarty Unannounced Inspection 3rd May 2007 09:15a 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 Willowmead DS0000013831.V339039.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. Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willowmead Address Willowmead Summer Road East Molesey Surrey KT8 9LR 020 8398 8664 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) Mrs Marion Davies Mrs Marion Davies Care Home 12 Category(ies) of Old age, not falling within any other category registration, with number (12) of places Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be over 65. One person to be accommodated may be under the age of 65. Date of last inspection 7th November 2005 Brief Description of the Service: Willowmead is a semi-detached home located in the village of East Molesey. The property backs onto the river and has a well-maintained, attractive rear garden that is accessible to the service users. There is limited parking to the front of the property. The home is owned and managed by Mrs Marion Davies and provides accommodation and care to twelve older people. There is an L shape lounge on the ground floor that provides separate seating areas. A dining room and a large, homely kitchen are also on the ground floor. All bedrooms are single occupancy with 7 having en-suite facilities, one bedroom having access to a single bathroom and three sharing access to one bathroom. The majority of bedrooms are on the ground floor. A stair lift is available to access rooms on the first floor, though three steps have to be negotiated at the top of the stairs, for which handrails have been fitted to aid access. There is a flat consisting of a bedroom, a lounge and a bathroom on the top floor, this is reached by stairs. The home also has a large summerhouse by the river providing seating, kitchen and bathroom facilities. Residents use the summerhouse for relaxation and the home for training care staff. Transport is provided by the home to access facilities in the local community and beyond. Fee levels for 2007/2008 start from 700 per week and are dependent on the assessed needs of prospective residents. Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and was the first key inspection carried out by the commission. The inspection took place over seven hours and a half (7) hours, commencing at 9:15am and ending at 4:20pm. Ms Susan McBriarty regulation inspector carried out the visit. The manager was available throughout the inspection. The inspection took into account the pre-inspection questionnaire information and records held at the home including the resident files, staff personnel files, training, medication administration and daily records. The inspector made observations of interactions between staff and residents during the visit and spoke with some of the residents and staff. Comments made by some of the residents during the visit have also been included in this report as had information from the seven surveys or comment cards were received from people who use the service. The pre-inspection questionnaire was received on the 10th May 2007 and confirmed that information given during the visit. What the service does well: What has improved since the last inspection? No requirements or recommendations were made during the visit of 7th November 2005. Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 6 No significant changes or developments had taken place since the last inspection. The home was considering further development to the home at the time of the visit on the 3rd May 2007. What they could do better: Some good practice recommendations have been made to assist the home to further improve their documents and records. One requirement is made to introduce a formal system of quality assurance. The original pre-admission assessment information had been archived off site. The manager was advised that keeping the documents on file at the home would enable them to audit more clearly any changes that might be taking place. The residents and the manager said that the home provided a flexible approach to providing care and support and the care plans and risk assessments would benefit from consideration as to how that flexibility is safely provided. Some work about how the home might record what activities were discussed with residents and either taken ahead or ended at their request would assist the home to further confirm how residents have choice and control over their lives. Safeguarding policies were in place however some policies and procedures related to safeguarding needed some update to show how information received might require referral under the local authority safeguarding procedures and further protect residents from abuse. The homes application forms needed minor amendment to ensure that all the information about a prospective member of staff’s previous employment history had been provided. This would further assist the home to ensure that their policy and practice of recruitment safeguards residents. Criminal record bureau checks were in place however a recommendation is made for the home to review the guidance provided by the Criminal Record Bureau with particular regard to storage and disposal. Informal systems were in place to assess the quality of the service and a requirement was made to ensure that the home develop and implement a formal quality assurance system that makes the outcomes known to residents and their relatives. Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Willowmead DS0000013831.V339039.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 Willowmead DS0000013831.V339039.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): Standard 3 was assessed. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home makes sure that they are able to meet the needs of people who wish to use to the service before they move in. Some action was needed to ensure that those written records remained available at the home. EVIDENCE: A number of residents’ files were sampled. The manager confirmed that all of the pre-admission information had been removed and archived in another location. One file for the most recent admission had assessment information completed by a local authority. A template for pre-admission assessments was seen. The manager said that they were training another member of staff to complete these assessments as part of their development. The assessment requests basic information about the person including address, date of birth and family contacts. Other information required includes medical information, background, likes and dislikes. The management of the home were advised to recall the assessment information and keep on the files at the home. This will Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 10 make sure that the care plans following on from the assessments continue to identify the same needs. Contracts were in place and held in a separate file. Seven (7) surveys were received from people who use the service; one said the contract would benefit from being more detailed. This standard was not assessed in full. Willowmead DS0000013831.V339039.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): Standards 7,8,9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, personal and social needs of people who use the service were met in a way that respected their privacy and dignity. A method of documenting the level of flexibility available in care planning would assist in confirming this. EVIDENCE: A number of care plans were sampled. Those viewed were found to contain details and times of what would happen during the day and how people’s needs were to be met. The care plans seen had been signed by the resident and last reviewed on the 21st April 2007. In discussion with the manager and people who use the service it was clear that there was flexibility within those plans although this was not clear in the care plans. See also daily life and social activities. The care plans sampled were discussed with the manager who was aware of the likes and dislikes of those people and that they preferred a clear routine to be in place when they were at home. The management of the home were Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 12 advised to consider how the record in the care plans can show how flexible the plan was and that the routine shown was at the request of the resident. Risk assessments were in place for a number of residents although one recently reviewed care plan suggested that a risk assessment might be useful due to their increasing level of assessed needs. Certificates in training for carrying out risk assessments were seen by the commission. The management of the home were recommended to review the use of risk assessments to make sure that they were in place where needed. See also the environment section of this report. Information from health professionals held by the home, care plans; discussions with residents and the daily records sampled confirmed that the health needs of residents were being met. For example letters from specialist health professionals and the daily records kept confirmed that doctors, chiropodists, a physiotherapist and other health representatives had been seen by residents. The home has a procedure in place for giving medication that set out what was expected of members of staff giving medication to residents. The policy would benefit from including information about what the staff must do if a resident wanted to self-administer their medication. The manager told the commission that a recent pharmacist visit to check how the home dealt with medication led to their being commended on how they deal with returns. The returns book shows that very little medication was returned to the pharmacist unused or unwanted confirming that appropriate ordering takes place. Written confirmation of the outcome from the pharmacist had not been received by the home. A number of records confirming what medication had been given to who were sampled and no errors were found. None of the people who use the service were self-administering medication. Members of staff giving medication had received training and the manager said that staff would not be allowed to add their signature to the medication administration records until a training certificate had been received confirming the completed training. Observations made by the commission and discussion with three residents and two members of staff confirmed that the home treat the people who use the service with respect and value the privacy of others. One person said that the ‘staff always ask what they want’ and that they ‘never impose’. The seven (7) Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 13 surveys received from people who use the service stated that their medical needs were always met. Willowmead DS0000013831.V339039.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): Standard 12,13,14 and 15 were assessed. 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 able to exercise choice and control over what leisure, social and religious activities they wish to attend and when and are offered a healthy varied diet. A method for confirming how and what decisions residents made would further confirm this. EVIDENCE: The home provided for twelve people, all but one were female and all were white British. The manager informed the commission that the home did not have information to give to people who use the service to show what activities were being provided and when during the week. The manager also said that the residents at the home had told her that they did not want such a list provided. The commission were informed that a number of different activities had been tried and that any initial enthusiasm went and the residents chose not to continue. However in further discussion with the manager, discussion with members of staff, residents and information in the daily records confirmation was found Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 15 that activities were taking place. Seven (7) resident surveys were also received; six (6) stated that activities were always available, one (1) said they were usually available. The care plans also confirmed some of the activities undertaken by residents, these included visiting friends, receiving guests including relatives, attending a place of worship and gardening. For example two trips took place every week and residents went to a variety of venues including Brighton. One resident said that they did not want to go out and this was respected by the home and that they were able to help out with some tasks in the home and that they enjoyed doing this. One member of staff confirmed that they had received training about how to provide activities and that the course had been hard but interesting. The home encourages residents to make choices and to take control of their lives however some thought about how this might be further confirmed would be useful. Please also see the section on personal and health care regarding similar matters. The home supports a flexible approach to provision and those residents spoken with confirmed this. However thought about how the home can confirm what had been offered and refused by the residents or where residents had changed their minds about what they wished to do may be helpful. Where able those service users spoken with said that the food provided by the home was very good. Observations made by the commission during the visit noted that fresh food was prepared and provided and that fresh fruit was readily available in one of the lounge areas. The menus seen as part of the visit and in the pre-inspection questionnaire confirmed that a varied diet was provided. Seven (7) surveys were received from people who use the service, one said the food was excellent and that special food was provided where needed. One resident was observed saying to staff that they were delighted at the addition to their lunch as it followed a comment made by them to a member of staff earlier that day about how they liked a particular food. Evidence was seen that members of staff had received training in food hygiene. Willowmead DS0000013831.V339039.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): Standards 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who use the service can be confident that their views are listened to and acted upon and that they are protected from abuse, minor changes were needed to further confirm this. EVIDENCE: A policy and procedure for dealing with complaints was in place. Those residents spoken with said that they felt they could talk to anyone in the home if they had a concern and would be confident that it would be dealt with. Seven (7) people who used the service returned surveys confirming that they knew how to make a complaint. Neither the home nor the commission had received any complaints since the last inspection on 7th November 2005. The views of residents are listened to and acted upon. The manager had developed the home’s policy and procedure for safeguarding adults that supported the multi-agency guidelines provided by the local authority and members of staff had received training in safeguarding matters. One person spoken with said ‘I feel safe here’. Other policies were in place including the ‘prevention’ of abuse, whistle blowing and dealing with harassment. The policies did not make clear the link between those policies and the safeguarding policy and procedure. A Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 17 requirement was made for the home to review those policies and procedures that might link to safeguarding matters and ensure a statement was entered making clear what the link was. This would further confirm that people who use the service are safeguarded from abuse. No safeguarding referrals had been made by the home or received by the commission since the inspection of the 7th November 2005. A restraint policy was in use, the manager said that restraint would not be used by the home and if any one using the service needed the level of support that required restraint she did not feel that the home would be suitable for their needs. The commission noted that if a restraint policy was in place that all members of staff needed accredited training and that suitable recording tools had to be in place. The manager immediately removed the restraint policy. Willowmead DS0000013831.V339039.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): Standards 19 and 26 were assessed. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who use the service are provided with a homely environment that is kept bright, fresh, clean and well maintained. Some work was needed to make sure that risk assessments were in place to continue to safeguard the residents. EVIDENCE: A full tour of the home did not take place due to the amount of time being taken by the commission. Residents were keen to speak to the commission and this meant that three of the bedrooms were not seen although all of the communal areas were. All the bedrooms seen were clean and well decorated and where possible had been personalised by the residents. Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 19 The building had been extended to the rear providing ground floor accommodation with en-suite facilities and glass doors that open onto the garden. The older part of the building was set over three floors. The top floor provides a bedroom, bathroom and living area for one person; the first floor bedrooms had shared bathroom facilities. A number of the bedrooms on the first and second floor had views of the river. A stair lift was available to the first floor if needed. The ground floor provides an L shaped communal living area, dining room and a large kitchen. The ground floor is wheelchair accessible through a door at the side of the building. People who use the service had been consulted about the access arrangements through the front door and consideration is being given to smaller steps with a handrail, as was their preference. The home was well decorated, bright, fresh and clean throughout and the communal areas provided a number of styles of seating for people who use the service to choose from. The people who use the service were able to access the garden area at any time they chose. No outstanding repairs or issues of concern were found during the tour or brought to the attention of the commission by the residents. Seven (7) surveys were received from people who use the service all confirmed that the home was always fresh and clean. The garden was well maintained, an area had been laid to lawn and others planted, much of the work needed had been carried out by one of the residents. At the rear of the garden a summerhouse was in place with seating, kitchen and bathroom provided. Outdoor seating had also been provided enabling a view of the river. Secure fencing was in place to safeguard residents. The manager said that the summerhouse was seldom used by the residents and thought was being given to extending the number of bedrooms available and removing the summerhouse. Pets had been welcomed into the home by the residents, one had specifically asked about a cat and the residents enjoyed having the managers’ dogs present. Some work was needed to consider expanding the provision of risk assessments regarding such things as pets and the use of air freshener that was seen as available for use. The manager was aware of these matters. Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 20 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): Standards 27,28,29 and 30 were assessed. 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 and protected by appropriate numbers of staff and the home’s policy and practice for the training and recruitment of care staff. Some action was needed to further improve their application procedure and to make sure the storage and disposal guidelines of other agencies documents are followed. EVIDENCE: A number people who use the service told the commission that members of staff always responded when they needed assistance and one said they always responded immediately and never made them feel as if they had ‘imposed’ on them. Seven surveys were received from people who use the service one said the ‘staff were very good’. The home employs ten members of staff. Two (2) members of the care staff were on duty at all times during the day and three (3) during the breakfast period. Members of staff worked on average between 8am and 6pm each day. The members of staff were able to negotiate times from 8am to 2pm, 4pm or 6pm as long as two remained on duty. The manager was not counted as a member of the care staff and was available during the day offering further flexibility to support. The manager’s partner dealt with a number of the activities, finances and escort duties. A full time cleaner was employed as was a cook who worked over six (6) days each week working late on a Friday as many of the residents are out on that Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 21 day. One (1) waking and one (1) sleep-in member of staff worked overnight from 10pm to 8am. During the inspection the manager told the commission that three (3) members of staff were doing the National Vocational Qualification (NVQ) level three and three (3) were doing their NVQ level 2. This will assist in ensuring that people who use the service are in safe hands at all times. Documents were seen that confirmed NVQ training had taken place. An equal opportunities policy and procedure for the recruitment of staff was in place. All the staff were white female from a variety of ethnic backgrounds. Recruitment records were viewed and the home had ensured that the correct checks had been made before they recruited that member of staff. For example completed application forms, references and identity checks. The application did not ask for all previous employment information including the reason for any gaps. The management of the home were advised that making this addition to the application forms would further assist in confirming that the home’s policy and practice for recruitment protect the people who use the service. Criminal record checks (CRB’s) were in evidence in all those files sampled. A CRB check makes sure that any prospective member of staff is not on the protection of vulnerable adults list and deemed as not suitable to work with vulnerable adults. The files had the original documents in place and it was recommended that the home review the Criminal Record Bureau guidance with particular reference to storage and disposal. Discussion with the manager, two members of staff, framed certificates in the hall and other training records confirmed that a range of training took place. This included induction, food hygiene, manual handling, fire safety the administration of medication, risk assessment and infection control. This ensures that appropriately trained members of staff support people who use the service. Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 22 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): Standards 31,33,35 and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health, safety and well being of people who use the service is supported and protected by the home’s practices and procedures. Improvement was needed to further confirm that the home was run in the best interests of residents. EVIDENCE: The manager told the commission that she had completed the registered managers award and was completing an NVQ level 4. Additional evidence of further training being carried out was seen including for example safeguarding adults and the administration of medication. Those members of staff spoken with said that they felt supported by the manager and could discuss any issue Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 23 with her. People who use the service live in a home that is well run and managed by the person in charge. Informal quality assurance takes place in the form of regular resident and staff meetings. Minutes were held of the meetings including outcomes and what action was needed. The minutes of some meetings were sampled and showed that where people who use the service had asked for something action had been taken. The home does not have a formal system of quality assurance that brings together the views of residents, members of staff, relatives and others and make known the outcome in a written format. A requirement is made for the home to develop such a formal system. This will further confirm that the home is run in the best interests of the people who use the service. The manager informed the commission that the home does not assist people who use the service with their money. Signed agreements were seen on the files sampled confirmed this. Evidence was seen of safety checks being completed confirming the information provided in the per-inspection questionnaire, these included fire protection in April 2007, fire alarm and emergency lighting on the 5th April 2007, six monthly nurse call system checks and the stair lift was serviced on the 30th April 2007. A locked cupboard was in use to store chemicals such as cleaners. As noted previously the home would benefit from expanding risk assessments to include such items as air fresheners in use in the home. Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 24 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 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 X X X X X X 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 X 3 X X 3 Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 25 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 OP33 Regulation 24 Requirement A formal system of quality assurance must be developed and implemented by the home. This will ensure that the home continues to run in the best interests of the people who use the service. Timescale for action 31/07/07 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 OP12 2. OP7 Good Practice Recommendations It is recommended that the home seek ways to record the flexibility of services provided at the home. This would confirm that residents maintain choice and control over their lives. It is recommended that the home review the provision of risk assessments to ensure that all aspects of people’s lives have been considered including such things as the use of air fresheners. It is recommended that an additional statement is added to policies and procedures such as prevention of abuse, harassment and others to make clear the link between DS0000013831.V339039.R01.S.doc Version 5.2 Page 26 3. OP18 Willowmead 4. OP29 those procedures and the safeguarding procedures. This will further assist the home to protect residents from abuse. It is recommended that the home review the criminal record bureau guidance with particular reference to storage and disposal. Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Willowmead DS0000013831.V339039.R01.S.doc Version 5.2 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. 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!