Inspection on 16/01/08 for Willowmead Residential Home

This inspection was carried out on 16th January 2008.

CSCI found this care home to be providing an Good service.

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 13/10/06

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 Sheila Knopp Unannounced Inspection 16th January 2008 09:05 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.V357411.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.V357411.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 managerw@goldcarehomes.com GCH (Willowmead) Ltd Kim Hirst Care Home 62 Category(ies) of Dementia (62), Old age, not falling within any registration, with number other category (62) of places Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of service users accommodated in the home must not exceed 62 persons Key Inspection – 13th October 2006 Random Inspection - 8th March 2007 Date of last inspection Brief Description of the Service: Willowmead is a residential home that offers accommodation for up to 62 older people requiring support with personal care who may also have dementia. The home is part of the Gold Care Homes group. Willowmead is divided into two completely separate buildings/units known as Hatfield and Wickham. Accommodation is provided on two floors of each building, with lounge and dining facilities on the ground floors. Passenger lifts in each unit provide access to the upper floors. There are fifty-six single bedrooms and three double bedrooms between the two buildings. Hatfield has a main lounge, smaller visitors lounge and a dining room. Wickham has one lounge/dining room. Residents have access to a large garden to the rear and side of the buildings. Willowmead is located in a rural setting and reached via a narrow public lane with no footpath. Visitors are able to park in front of the properties. The nearest town/village is Hatfield Peverel, which is approximately 2 miles away. There are no direct public transport links. The current fees for privately funded people range from £450 - £550 per week depending on an assessment of care needs and room size (correct on 16/1/08). Different rates per bed are charged where local authorities are responsible for funding arrangements. Guides to the home, in the form of a Statement of Purpose and Service User Guide, can be obtained on request from the manager together with a copy of the latest inspection report. Inspection reports are also available on the CSCI web site. Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The information in this report is based on an unannounced inspection to Willowmead by one Regulation Inspector. For the purposes of this report the Commission is referred to as ‘we’. We met with the people who live in the home, their visitors, a visiting health care professional, staff and the management team, to gather their views and experiences on the quality of the service provided. We also made survey forms available to residents, relatives, health care professionals and staff so a wider group of people could have their views included in our assessment. We looked at information we have gathered since our last key inspection undertaken on the 13/10/06. This included an additional (random) evening unannounced inspection on 8/3/07 following a complaint from the East of England Ambulance service. This service has continued to improve between inspections and the company have put management systems in place to make sure this is a continuous process. What the service does well: There is a warm, relaxed atmosphere in the home. Residents said they have a good relationship with staff. Those unable to voice their opinion responded well to staff they came into contact with during the day. A relative said ‘I cannot speak highly enough of the staff, all of whom are friendly and efficient’. Another relative said ‘I think the care home does an excellent job in looking after people in their care’. The people we spoke to and those who completed survey forms told us they enjoy their meals. There are very good links with local community nursing and general practitioner services, which ensures, people’s health needs are met and kept under review. Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 6 An enthusiastic activities organiser provides a range of activities, events and points of interest to keep people occupied during the day and encourage a sense of community. The rural setting means that many of the residents enjoy the wildlife that comes into the garden and have birdfeeders outside their windows for a closer view. What has improved since the last inspection? What they could do better: The manager has confirmed that the arrangements for storing medicines are being reviewed to make sure they are kept at an appropriate temperature to maintain their safety and effectiveness. To maintain the dignity of residents the stained carpets and dining chairs in the Hatfield house dining room need to be replaced. A relative said ‘My only dislike was the mess on the back of the dining chairs they could have been either cleaned better or covered in a wipeable material’. Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 7 Now that the garden has been fenced, adding wheelchair accessible pathways and features so people can walk with purpose and find quiet areas to sit would enhance the provision being made for people with dementia and limited mobility. 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.V357411.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.V357411.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 (standard 6 does not apply to this service) People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs are fully assessed before they move into Willowmead so the individual and home can be sure the service is right for them. EVIDENCE: To find out people’s experience of moving to Willowmead we spoke to 2 people who had recently moved in and the relatives who were visiting them. One person told us they had been made to feel welcome, had settled in and were enjoying the company of others and the meals. They had developed a good rapport with staff and were being encouraged to maintain their skills and interests. A care plan had been put in place to let staff know what their preferences and care needs were. Another person confirmed the deputy manager had visited their relative at home to carry out an assessment before they came to stay. Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 10 We also looked at how the home assessed whether they can meet the needs of each individual by looking at their care records. We spoke to the manager, 2 deputy managers and care staff to identify their understanding of the admission process and needs of people who have dementia. We found that information is obtained from local authority care managers and medical services, involved in the admission process, so a full picture of care needs is obtained. The deputy manager was able to tell us how the assessment process continued following admission, to make sure people were closely monitored and health care professionals brought in where required during this vulnerable time. The number of people the home can admit who have a diagnosis of dementia has increased since the last key inspection. We have issued a new certificate to reflect this and the home have updated their Statement of Purpose and Service User Guide. This is so people have clear information on how people with dementia will be supported and the services they can expect. Staff spoke of the benefits to residents of recent dementia care training they have received. They felt it had given them greater insight into the day-to-day experience of people with dementia and how to support them. Willowmead Residential Home DS0000064381.V357411.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 & 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people who live at Willowmead can expect to have individual care plans that are kept up to date so staff know how people wish to be supported and cared for. Residents who require medication can be confident that this will be given safely and it will be regularly reviewed to make sure it is still required to meet their needs. EVIDENCE: To assess whether the personal care needs of people were being met according to their individual wishes, we met with residents in the lounges of each house and people who choose to spend time in their rooms. We also talked to staff and looked at care plans to see whether they had the information needed to respond appropriately to care and health needs. Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 12 The residents we met had received good attention to their personal care and hygiene needs. Staff supported the dignity of residents by adjusting or changing clothing as required during the day. Many were attending the hairdresser on the day of our visit. People confirmed staff were sensitive when providing intimate care and that they enjoyed their baths. Three out of 4 people who returned the survey forms said the home always met the needs of their relative. One person said this was usually the case. The care plans provide staff with information about the personal preferences and care needs of each individual. Individual problems are identified and provide staff with instructions on how they should approach specific situations. A company audit has identified the need to invite residents and / or their representatives to agree and sign the plan of care following admission and as changes are made to it. This is being addressed by the manager. We found that there was a good approach to monitoring people at risk of falls to reduce the risk of injury and identify those who needed further medical assessment or referral to falls prevention services. People at risk of developing pressure sores had been provided with specialist equipment on their beds and chairs to reduce the risk of problems in the future. We noted that risk assessments were in place for individuals where specialist equipment, which may restrict free movement, such as bed rails or recliner chairs were in use. Extending this approach to cover people who bring their own domestic style recliner chairs into the home with them was discussed with the manager. This is to make sure each person’s ability to use the equipment safely is kept under review and the appropriate use and servicing needs are monitored once the equipment has been accepted into the home. People who required specialist support and monitoring had been referred to the community nursing services. A practice nurse present on the day of our visit was carrying out a review on a person with diabetes. Information in the care plans told us that people had access to dentists, chiropodists and opticians. Staff told us of the support and advice provided by community continence and mental health services. To check that medicines are being given safely we checked the systems for ordering, storing administration and disposal. No one at the time of this visit was managing their own medication. The company audit has identified the need to put a system in place to enable people to maintain independence in this area of their life. The care records and administration charts show that the local GP carries out regular reviews. There was a low use of medication to manage behavioural Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 13 problems and one of the deputy managers reported staff are not giving any medication of this type under their own discretion. There were good systems in place to alert staff to changes in medication and track information and advice provided by the GP, pharmacy and hospitals so staff are kept up to date. We identified that the medicines were not being stored at the correct temperature and further secure storage was now required to meet a change in legislation that applies to care homes for the first time. To address this the manager has confirmed that the medicine room on Hatfield house is being moved and a drug refrigerator and controlled drug cupboard are being ordered. Willowmead Residential Home DS0000064381.V357411.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): Standards 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people who live at Willowmead can expect to be offered a range of activities suited to their needs that will provide opportunities for stimulation and enjoyment. The people who live at Willowmead can expect to be offered a varied choice of meals that will meet their needs. EVIDENCE: On the day of our inspection we observed activities being organised in both houses by the activities organiser. Eleven out of 12 people who completed survey forms said there was always / usually activities arranged which they could take part in. With the support of relatives, profiles are being developed for each person as part of their care plan so staff can have a greater understanding of their past lives and provide a more individual response to their social and emotional needs. Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 15 A resident who chose to spend time in their own room reported that staff came in to visit them and they enjoyed watching the wild life and birds visiting the bird feeder outside their room. A relative commented that staff spent time with the residents and they were not just left to watch the television. ‘There is plenty of entertainment and I feel they treat the residents as human beings’. The activity organiser was able to provide us with detailed information about the events organised within the home and outside. Pictures of residents taking part in activities are displayed on notice boards so relatives can see what has been going on particularly where residents are not able to communicate this information themselves. The visitors we spoke to commented on the friendly welcoming atmosphere in the home. Staff addressed them individually by name and made enquiries about their well-being. Tea and coffee is offered. One person told us they were invited to have meals with their wife. A relative said that staff had an understanding of the needs and difficulties of being a husband or wife of someone who lives in a care home. A quarterly newsletter encourages a feeling of community and lets residents and relatives know what is going on in the home. The residents we spoke to enjoyed their meals. Seven out of 12 people who completed survey forms with assistance from the activity organiser said they always enjoyed their meals. Three people said this was usually the case. Fresh fruit and drinks are available for residents to pick up. A relative told us about the encouragement given to coaxing a new resident to eat. Staff were observed to be sensitive to the needs of people that needed support to eat their meals and were available in sufficient numbers to spend time sitting with each person. Willowmead Residential Home DS0000064381.V357411.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 & 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People can feel confident their concerns will be listened to and acted upon, and that they will be protected by trained staff who create a positive and supportive culture within the home. EVIDENCE: To find out how concerns are dealt and people are protected we spoke with service users, their relatives, staff and the manager. We looked at the record of compliments, concerns and complaints received by the home since our last key inspection. We reviewed information we had received from the local ambulance service about the approach of staff during an emergency visit and survey forms we received after our visit. Everyone we spoke to felt that the manager and staff were approachable. Information about how to raise concerns is readily available around the home. The manager has introduced comment books in the entrance to both buildings so people can make suggestions. Residents and relatives meetings also provide another opportunity to comment on the running of the home. Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 17 Ten out of the 12 residents who returned completed survey forms confirmed that staff listened and acted on what they said. Seven out of 12 people who completed our survey said they knew how to make a complaint. Only 4 people said they knew who to speak to if they were unhappy. This may indicate that the manager needs to develop this further as part of the key worker role with individual residents. We have not received any complaints about this service from residents or their relatives between inspections. The manager has kept a record of informal discussions with relatives but has not received any formal complaints, which required investigation. Over the last year the manager has received many cards and letters thanking staff for the care provided. We carried out an additional unannounced evening inspection on 8/3/07 to look at a complaint from the East of England Ambulance service. Day and night staff now have access to a photocopier so relevant information can be copied quickly and sent with the resident to hospital. The manager reported procedures for contacting and responding to the emergency services have been reinforced with staff, through supervision. The training programme includes updating all staff on safeguarding procedures to protect vulnerable people. Details of the local authority procedure that staff should follow in the event of problems being identified were available for them to refer to. We have evidence that the manager has a sound understanding of her responsibilities in this area and takes appropriate action. We asked care and domestic staff whether they had any concerns about care practices or the approach taken to residents. No issues were raised but staff are aware of their responsibilities to report any concerns. A senior worker observed that over the last year the newly appointed staff team had created a positive culture within the home. Staff said they would be able to raise any concerns they had with the manager and senior staff. The manager reported the company are reviewing the implications of the Mental Capacity Act on their procedures; care planning and security systems to make sure people’s rights are supported. Willowmead Residential Home DS0000064381.V357411.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 & 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at Willowmead generally live in a safe, pleasant environment that meets their needs. Refurbishment is continuing to ensure all areas are brought up to acceptable standards. EVIDENCE: To look at the accommodation, comfort and cleanliness of the services provided to the people who live at Willowmead we visited both houses and looked at the public areas, grounds, spot checked individual rooms and visited the laundry and kitchen in both houses. The manager also provided an update on the work carried out since our last visit. We were able to meet the domestic, laundry catering and maintenance staff that were on duty. Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 19 Many areas of the home have been decorated and refurbished to good effect. Particularly pleasing are the large block prints of film stars from the past and tactile pictures. The manager reported she is gradually replacing the worn bed linen and providing matching bed covers. Window restrictors are fitted to windows above ground floor level and the hot water supplies are regulated and radiator surfaces covered to prevent accidents. Fencing has been erected around the large garden to provide a secure and private area for residents to spend their time in. This is a positive step as resident access to the garden over the previous summer was restricted. The manager is aware that the small patio areas outside the lounge windows need attention, to make sure their surfaces are even and they are not a hazard to residents. Further landscaping of the garden areas giving consideration to the needs of people with dementia and wheelchair users would improve these areas further. A relative commented that ‘There could be better wheelchair access to the outside and gardens’. Overall good standards of hygiene and cleanliness were observed in the majority of areas accessible to residents. However the dining chairs and carpet in Hatfield house are heavily stained and do not promote the dignity of people living here. Requirements have not been made at this stage as the manager reported that these are due to be replaced as part of the refurbishment programme. The manager has been requested to update us on the outstanding work to be carried out together with planned timescales so we can monitor progress. The manager is taking steps to address odours, which arise in specific areas of the home on a daily basis due to the lack of awareness on the part of individual residents. The surface coating on the kitchen cupboards in both houses is worn, revealing the underneath fibreboard. This means that they cannot be adequately cleaned. To address this the manager has advised us that quotes for new cupboards are being obtained ahead of an environmental health inspection in March. To prevent the spread of infection liquid soap and disposable paper hand towels are available in individual rooms and areas where personal care is carried out. Staff confirm disposable gloves and aprons are always available to them. The manager replaced some broken pedal bins and removed nailbrushes from communal use during our visit to maintain good infection control practices. Willowmead Residential Home DS0000064381.V357411.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 & 30 People who use the service experience good quality outcomes in this area This judgement has been made using available evidence including a visit to this service. The people who live at Willowmead can feel confident that the staff who support them have been checked for their suitability to work with vulnerable people and receive regular training and supervision to make sure they continue to provide a good service. EVIDENCE: Seven out 12 residents who returned completed survey forms said there were usually staff available to meet their needs. Three people said staff were always available. The people we spoke to confirmed they enjoyed good relationships with the staff. The interaction we observed was gentle and encouraging. A health care professional said staff were ‘caring’ and showed ‘concern’ for the residents. From our observations a satisfactory number of staff were available during the day to meet the needs of the people they were supporting in a timely way. This included being able to sit with individual people to talk with them or provide support at lunchtime. The manager reported that unannounced visits are made to the home at night so senior managers can check on standards through out the 24 hour day. One resident who completed a survey form said there should be more night staff. Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 21 We looked at the records of 4 staff recruited since out last inspection and were able to confirm that the required checks on their suitability to work with vulnerable people are being carried out. These include checks on previous employment, qualifications and a criminal record. Details of the induction programme new staff complete to make sure they have the necessary skills to carry out their work safely were seen and confirmed by a new member of staff. The manager has put a training programme in place to make sure staff are kept up to date and new staff are given the skills they need. In line with the home’s registration to support people with dementia the aim is to provide new staff with dementia care training within the first 6 weeks of employment. To gain the views of the wider staff team we left 25 survey forms with a member of the care staff team to distribute to fellow workers. We received 4 completed forms. Two people said their were always enough staff and the other 2 said this was usually or sometimes the case. Two people commenting on what the service does well listed, the caring approach to residents, up to date training and working as a team. Willowmead Residential Home DS0000064381.V357411.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 & 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The people who live at Willowmead are supported by a management team with experience in meeting the needs of older people. The policies and procedures of the service promote the health and safety of the people who live and work at Willowmead. The quality of the service provided is regularly reviewed to make sure standards are improved and peoples rights are protected. Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 23 EVIDENCE: To review how well the management systems are supporting the needs of the people who live at Willowmead and the health & safety of residents and staff we had discussions with the manager, two deputy managers and staff on duty. We reviewed the surveys we have received and looked at relevant health & safety records. Since our last key inspection we have confirmed the registration of the manager as required under the Care Standards Act following checks on her integrity and experience. The manger has achieved the Registered Managers Award (RMA), which is the standard management qualification set for managers of care services. The manager, 2 deputy managers and 3 team leaders are also working towards qualifications at NVQ level 4 in care. This will mean that the home will have a well-qualified management team to support the needs of the people who live in the home. Staff told us that management team were supportive and approachable. Four people who returned staff survey forms confirmed that the manager met with them regularly/ often to provide support and discuss how they were working. The home has met the requirements we made following the last inspection. This shows us the company are working with us to meet its statutory obligations and make improvements for service users. We saw records of the audits being carried out by the home manager and area manager to review and improve the quality of the service being provided. There are plans for other managers within the Goldcare group of homes to be involved in reviewing the services provided in other homes to provide an external view. The manager reported she will be involved in the next round of business planning and priority setting for the home, which has seen considerable financial resources allocated to improving environmental and training standards in the last year. The Annual Quality Assurance Assessment (AQAA) was sent to us by the manager when we requested it. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us numerical information about the service. The completed AQAA identifies areas of improvement and areas for further development. The manager provided us with a copy of the company quality assurance report (28/6/07), which includes the views of residents, relatives, staff and community health professionals who have regular contact with the people who live at Willowmead. The manager was able to show us that many of the issues identified from the homes own survey of residents and relatives had now been addressed. Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 24 Clear records of payments and deposits made by or on behalf of residents are kept so any transactions can be tracked and checked to make sure people’s financial interest are looked after. The maintenance and service records we checked were up to date. There is a training plan in place to make sure staff receive the regular updates they require to maintain safe working practices. Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 25 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 2 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 3 x 3 x x 3 Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations The company should let the manager know when they plan to replace the stained dining room chairs and carpets on Hatfield house as part of the refurbishment programme so residents and their relatives can be assured of the steps being taken to promote their dignity and make this a pleasant place to be. Willowmead Residential Home DS0000064381.V357411.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Inspection Team Area Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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.V357411.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. 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