Inspection on 13/10/06 for Willowmead Residential Home

This inspection was carried out on 13th October 2006.

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 Residential Home 16/01/08

Willowmead Residential Home 14/03/06

Willowmead Residential Home 04/08/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Willowmead Residential Home Wickham Bishops Road Hatfield Peverel Essex CM3 2JL Lead Inspector A Thompson Key Unannounced Inspection 13th October 2006 10:30 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 Residential Home DS0000064381.V316525.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 Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willowmead Residential Home Address Wickham Bishops Road Hatfield Peverel Essex CM3 2JL 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) 01245 381787 01245 382356 Wickham Bishops Nursing Home Ltd Vacant Care Home 62 Category(ies) of Dementia - over 65 years of age (22), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (1), Old age, not falling within any other category (62) Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 62 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 22 persons) One person, aged 65 years and over, who requires care by reason of a mental disorder, whose name was made known to the Commission The total number of service users accommodated in the home must not exceed 62 persons 14th March 2006 Date of last inspection Brief Description of the Service: Willowmead is a residential home which offers accommodation for up to 62 older people (over 65 years). The home has been under new ownership since February 2004. The name of the new owning organisation NHCH Limited, was changed again in April 2005 to: Wickham Bishops Nursing Home Ltd. This was a change of company name only. Willowmead is located in a rural setting with no direct public transport links. The nearest town/village is Hatfield Peverel, which is approximately 2 miles away. The home is divided into two completely separate buildings/units. One is called Hatfield, the other is named Wickham. Accommodation is on two floors in both buildings, with lounge and dining facilities on the ground floors. Access between floors is provided by a passenger lift in each unit. There were fifty six single bedrooms and three double bedrooms between the two buildings. Hatfield has one main lounge and a smaller visitors lounge along with one dining room. Wickham has one lounge/dining room. The home has gardens to the rear and side of the property; these were spacious but in need of attention to enable residents’ better access and use. The home is reached via a narrow public lane with no footpath, ample car parking is provided for visitors at the front of the properties. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 5 Information on weekly fees is available from the home. Past inspection reports are available from the home, and from the CSCI internet website. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on Friday 13th October 2006, with a second arranged visit on Monday 16th October 2006. The content of this report reflects the inspector’s findings on the day/s of the inspection along with information provided by the service and feedback by service users, relatives, staff and other parties. Practice and procedures occurring after this inspection will be reported on in future inspection reports. Random samples of records, policies and procedures were inspected and a tour of parts of the premises and grounds took place. Discussions took place with service users the manager and staff. Many residents were unable to express any views on the service owing to their diagnosed dementia. Those spoken to who did have a view confirmed they were generally satisfied with the care they received and with the quality of the food and accommodation offered. Questionnaires were left at the home for relatives to complete, to ensure they had the opportunity to make their views on the service known to the Commission. Staff confirmed they received support from management. They also confirmed that they had been offered training appropriate to their role. Twenty-six standards were inspected with twenty-two met and four almost met. What the service does well: What has improved since the last inspection? New carpets had been fitted in Hatfield to the front stairs, landing, office and hallway. The kitchen had been commercially cleaned, and new floor covering had been laid in the kitchen and the adjacent serving area. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 7 What they could do better: One bath in Wickham was out of use as it was cracked and holed, this requires attention. One bath in Hatfield had been completely removed, a replacement bath or shower must be fitted. Testing of portable electrical appliances had begun but needs to be completed. The premises risk assessments should be reviewed/updated and a summary of the quality assurance process for 2006 should be available for inspection. ----------------------- 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 Residential Home DS0000064381.V316525.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 Residential Home DS0000064381.V316525.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s assessment format and process ensured that initial perceived needs were identified upon admission. EVIDENCE: The manager or deputy manager visits all prospective new residents to assess their needs. Evidence of this process was seen in care plan files for residents admitted since the last inspection. A pre-admission assessment form is completed covering personal care, diet, weight and food preferences, sight, hearing, speech, oral needs, mobility (a falls & manual handling risk assessment is completed separately), medication, continence, psychological, social & hobbies, lifestyle, dislikes & background information with next of kin contacts. Care plans are compiled after admission. All prospective new residents are invited to visit before deciding on moving in on a month’s trial placement. Usually relatives will visit with the service user. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 10 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): 7,8,9,10 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 care needs of residents were adequately detailed in individual plans of care. Health care needs of residents were met and residents felt they were treated with respect. EVIDENCE: Care plans seen included personal and background information, next of kin details, GP, a full initial needs assessment, including care needs, lifestyle, social, physical, diet, medical, psychological needs, communication & skills. The full daily plan of care is compiled after admission under headings of: food/drink, toilet, health & hygiene, physical & mental abilities and social interaction. These headings are then broken down into sections of problem/need, aims/expected outcomes and care action required from staff. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 11 Care plan files also included records of GP visits (a weekly surgery is held in the home in addition to visits on request), weight, falls risk assessment, general risk assessment, manual handling risk assessment. The home has a visiting dentist who will provide domiciliary visits to residents. Some residents still visit their community based dentist. District nursing support is regular. Pressure sore risk assessments were included in care plan files. District nursing services provide pressure relieving aids and equipment. Continence advice is through a local hospital, in-house training has been provided to staff on this subject, records of this were seen. Specialist nutrition advice is sought through the GP practice, with speech therapy advice also available. Hearing tests also at a local hospital in Maldon after referral from the GP. An optician and chiropodist visit the home at regular intervals. One service user visits an optician in the community, with staff escort. GP services are provided by a local practice in Hatfield Peveral. Evidence was seen to confirm that staff receive certificated training in medication procedures on a course entitled “Safe Handling of Medicines”, this includes a competency assessment. The homes medication policy and procedure was unchanged. This covered areas of ordering, storage, administration, returns of unused stocks. A separate returns book/pad is maintained and was available for inspection. Only senior staff re-order and check in medication. A new manager had been appointed since the last inspection who is a trainer on medication, and will be providing this to staff in-house in future. Discussions with individual residents indicated that they were treated with respect by staff although there are many residents in Willowmead who are unable to express their views and feelings about the support from staff. Staff on duty were seen to be friendly and relaxed in their dealings with residents, and residents spoken with said staff were helpful and kind. Some residents had private phones in their rooms. Remaining residents had use of the home’s portable phone to receive calls. Residents spoken with confirmed that they wear their own clothes and that staff use their preferred term of address. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 12 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The lifestyle experienced within the home largely matched the expectations of residents. They were able to maintain contact with family, friends and participate in the local community. Residents were offered a varied, appealing balanced diet and were supported to exercise choice in their daily lives. EVIDENCE: Residents said that staff took account of their choices and preferences concerning daily routines. They also said they had a choice at meals. Residents/relatives meetings had taken place, records of a meeting on 18/9/06 were seen. Discussions had included services, staff attitudes, laundry and privacy & dignity. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 13 There was an activities co-ordinator in post who works 30 hours per week. Activities had been offered to residents five days a week. Records had been kept and included: puzzles, music, games, flower making, bingo, quizzes, painting, 1-1 discussions, charades and baking cakes. Entertainers are brought in monthly and regular outings had taken place using a hired mini bus. These included theatre, butterfly farm, garden centre, Maldon, Heybridge and afternoon tea out. A church service is held in the home monthly. There was also a visiting clothes shop and a mobile library calls very month. The activities co-ordinator had attended training on providing activities for people with dementia. The content of this had covered areas of planning, purpose, motivation, communication, involving the community, physical activity, therapeutic activity and resources. The manager confirmed that work was still due to take place on further improvements to the grounds to enable better resident access and ease of use. Relatives and friends are able to visit at all reasonable times. Information on visiting is in the statement of purpose and service user guide. All but three rooms were single occupancy which ensures privacy. There was also a small lounge in Hatfield unit available for residents to see their visitors separate from the main communal areas. Information is displayed in the home on how to contact external advocates. Inspection of private rooms confirmed that residents had been permitted to bring their own personal items with them on admission. There was also confirmation of this direct from residents, who told the inspector of the furniture and personal items they had been permitted to bring in with them. Residents spoken with who could express an opinion said that the food was good and there was enough of it. Nutrition records and menus had been kept. Food stocks seen were acceptable. The kitchen was considered small for the size of the home. A new laminate flooring had been laid in the serving area adjacent to the kitchen. The dining room furniture in Hatfield was in need of a clean even thought this was all relatively new. The manager advised this may have to be completely replaced as the fabric construction was difficult to keep clean. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 14 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents knew how to complaint and the home’s complaints procedure allowed for residents and relatives to formally raise any concerns or areas of dissatisfaction with the service. The home’s adult protection policies, procedures and practices were aimed at ensuring residents welfare. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 15 EVIDENCE: The complaints policy contained information on who to complain to with expected response times. Contact details of the current registration authority were up to date. Residents spoken with said they knew who to speak to in the home if they any concerns, and that in the past management had responded positively to any queries/issues they had raised. The home had a standard recording template document for complaints. There had been six recorded complaints since March 2006 with evidence seen of investigation and outcome. The written guidelines in place concerning the protection of vulnerable adults procedures included the Dept of Health guidance on POVA (Protection of Vulnerable Adults) procedures, and guidance booklets (issued to staff) from the Essex Vulnerable Adults Protection Committee. There was also a POVA referral flowchart on display for staff to use if issues of concern arise, this included 24 hour contact telephone numbers. Evidence was also seen to confirm that the manager had followed POVA guidelines where appropriate. Staff had received training on adult protection issues (POVA), documentary evidence of this was available. Future training will be provided in-house. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 16 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): 19,20,21,23,24,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Furnishings in the home looked comfortable but the work to redecorate and refurbish some communal areas needs to continue. Private accommodation was comfortable and suited to needs and preferences. The premises were accessible, appeared safe but not all facilities were available for use. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 17 EVIDENCE: The premises were inspected. Doors to some bedrooms on the ground floor in Wickham unit were in need of attention still. The new manager undertook to address this. Some areas of communal corridor carpeting on the ground floor and front stairs in Hatfield unit had been replaced. One of the baths in Hatfield had been taken out, this needs to be replaced and there is a statutory requirement included in this report. There was also a split/holed bath in Wickham, this needs replacing and this issue is also included as a statutory requirement. There are two maintenance staff employed (one x full and one x part time) in the home. The manager advised that general maintenance and gardening in and around the home is undertaken by these staff. Some improvements had been made to the grounds but further work was still scheduled to enclose the rear garden. Premises standards include: Hatfield unit had a main lounge and a smaller lounge adjacent (mainly used as a visitors lounge). There was also a separate large dining room in Hatfield unit. Wickham unit had just one lounge/dining room. Activities take place in the lounges. Some areas of the garden were enclosed and were accessible to residents, some rooms overlooked the improved ‘quadrangle’ garden. Lighting in communal areas appeared sufficient for residents needs. Furnishings in the lounges were adequate. There were sixteen communal wcs, (eleven in Hatfield and five in Wickham). One bedroom in Hatfield had private en-suite wc, twelve bedrooms in Wickham had private en-suite wc. There were five bathrooms (one fully assisted) and one ‘walk-in and one seated shower rooms in Hatfield unit, with four bathrooms (one with fixed hoist and one with portable hoist) and one shower room in Wickham. There were grab rails in corridors and raised toilet seats in some wcs. Each unit had a shaft passenger lift. Hatfield unit had two lifts. A staff call system was in place throughout. Storage facilities for wheelchairs was limited. Residents hold keys to their private rooms if they wish. Some rooms had external bolts fitted. The manager must ensure that usage of these is strictly Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 18 controlled, taking account of risk assessments and potential adult protection considerations. Individual rooms inspected were adequately decorated and many contained personal items and possessions. The home was clean and acceptably tidy on the day. Residents spoken with, who expressed a view, said they were satisfied with their rooms and the facilities provided. All radiators seen had low temperature surfaces. All bedrooms and communal rooms seen had central heating. Tests for Legionalla had been carried out. The laundry was sited in Wickham unit and met the standard, although small for the size of the home. There were two industrial type washing machines and one industrial type tumble dryer. Floors and walls were considered easily cleanable and impervious. The manager has advised that training in infection control had been provided to staff. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels appeared to meet the needs of residents, although the home was not full and staffing levels when full must not be reduced from those in place at time of registration. Staff had been provided training opportunities to equip them with the skills for their role, although it understood that not all had been able to participate in NVQ awards training because of lack of funding. Staff recruitment procedures aimed at the protection of residents had been followed Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 20 EVIDENCE: Since the last inspection the management team had been further increased to include two deputy managers as well as the three shift leaders (one at night). Care staffing levels were a maximum of nine in the mornings with eight in the afternoons and five at night. This appears to represent a reduction in staffing levels in place at the time of registration. If so this will not be acceptable to the Commission. This issue will be reviewed separate from this report to ensure that daily staffing levels when the home is full are no lower than when registration took place. Separate staff are rostered to undertake, cooking, domestic, laundry, administration and maintenance duties. Staff recruitment records were inspected. Evidence was seen that an interview is held, CRB checks are undertaken, two references obtained, application forms completed, proof of identity obtained, including a photograph, medical statement completed and training records kept. Discussion with staff and individual staff training records evidenced courses undertaken by staff included: medication, infection control, pressure care, diet & nutrition, first aid, POVA, health & safety, fire awareness, food hygiene, manual handling, NVQ and continence. The new manager is a trainer on medication, manual handling and an NVQ assessor. New staff employed confirmed that they were receiving induction training. The format used was seen and included safety/welfare, person centred care, role of the worker, health & safety, effects of the setting on service provision. At the next inspection records will be checked to ensure that this package is used for all new employees. The company general induction included structure, staff meetings, employment issues and care planning, evidence of this has been seen. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had been run and managed efficiently and effectively. Procedures for gaining the views of residents and relatives were in place and had been implemented but a summary of the findings was needed. Records required by regulation were in place. Financial practices in the home appeared to have been competently managed. The health and safety of residents could not be assured until testing of all portable electrical appliances has been completed. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 22 EVIDENCE: A new manager had been employed in August 2006 who will be applying for Registration with the Commission. The home’s quality assurance (QA) statement provided in depth information and guidance on quality service management, this defined areas for inclusion and specified outcomes. There was an in-house QA questionnaire which included asking for views on staff availability, attitudes, and atmosphere in the home, food, cleanliness and care. This had been circulated in 2006 however records were not available of the feedback and of any resulting actions due to be taken by management. There is a recommendation in this report on this point. During this inspection it was evident that the manager wishes residents to consider that they can speak with here whenever she is free, if they have any queries or concerns they want clarified. Some residents personal allowance monies were held for safe keeping by the home. Records of transactions, receipts and balances held were kept and were inspected. Random samples of records required to be kept were inspected, these included: assessments, background information and next of kin details, inspection reports, care plans, staff rota, regulation 37 notices, visitors, fire drills & procedures, regulation 26 reports, recruitment, cash held for safekeeping and accidents. All seen were satisfactory. Staff had received training in health & safety, manual handling, first aid, food hygiene, fire safety and infection control. Water storage had been checked for Legionella risk, hot water supply was not tested. There was a premises risk assessment in place, but this should be updated/reviewed. COSHH data sheets were seen. Evidence was seen to confirm that emergency lights, fire alarms & equipment, staff call bells, hoists, electrical installation supply and passenger lifts had all been tested/serviced within the required timescales. The home does not have a mains gas supply. Broken window restrictors identified in the last inspection report had been repaired. The testing of portable electrical appliances in the home had started but this must be completed. There is a statutory requirement on this issue in this report. Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 3 X 3 X 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 2 3 2 X 3 3 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 X X 2 X 3 X 3 2 Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23 Requirement The registered provider must ensure that the cracked/holed bath in Wickham is replaced. The registered provider must ensure that a replacement bath or shower facility is installed in the ground floor bathroom in Hatfield, (bath was fitted and has been removed since the last inspection). The registered provider must ensure that testing of all portable electrical appliances in the home is completed, with evidence records available for inspection. Timescale for action 31/12/06 2. OP19 23 31/12/06 3. OP38 13 31/12/06 Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 25 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 OP33 Good Practice Recommendations The manager should ensure that evidence is available for inspection of the findings and of any actions resulting from the 2006 quality assurance exercise. The manager should ensure that the premises risk assessments are reviewed/updated. 2. OP38 Willowmead Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Residential Home DS0000064381.V316525.R01.S.doc Version 5.2 Page 27 - 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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