Inspection on 09/05/07 for Willows Court

This inspection was carried out on 9th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Willows Court 07/01/10

Willows Court 24/06/09

Willows Court 14/01/09

Willows Court 18/02/08

Willows Court 18/05/06

Willows Court 07/11/05

Willows Court 08/08/05

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Willows Court 107 Leicester Road Wigston Leicestershire LE18 1NS Lead Inspector Ruth Wood Key Unannounced Inspection 9 May 2007 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willows Court DS0000063757.V335966.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. Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willows Court Address 107 Leicester Road Wigston Leicestershire LE18 1NS 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) 0116 2880223 0116 2880223 BestCare Limited Mrs Amanda Cooke Care Home 29 Category(ies) of Dementia - over 65 years of age (18), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (18), Old age, not falling within any other category (29), Physical disability (24), Physical disability over 65 years of age (24) Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. No one falling within category PD or PD(E) may be admitted into Willows Court when there are 24 persons of category PD or PD(E) already accommodated in the home No one falling within category MD(E) or DE(E) may be admitted into Willows Court when there are 18 persons of category MD(E) or DE(E) already accommodated in the home Rooms 21, 22 and 23, within Willows Court are not to be used for residents who fall within categories PD or PD(E) No one under 55 years falling within category PD may be admitted into Willows Court No one falling within category OP may be admitted into Willows Court where there are 29 persons of category OP already accommodated within the home To be able to admit the named person of category PD named in variation application number V32221 dated 15th May 2006 The maximum number of persons accommodated within Willows Court is 29 18th May 2006 Date of last inspection Brief Description of the Service: Willows Court Residential Home offers care to a maximum of 29 people. The home is a modern property situated in a quiet residential area of Wigston town and is accessible by main road routes and bus services. Accommodation is over three levels with the majority of bedrooms being on the first and lower ground floors. All levels of the home are accessible by a passenger lift. There are two lounges and a dining area with a conservatory attached. Smoking is only permitted in the conservatory area. There are six shared rooms with en-suite facilities. Eric the cat lives at the home and the rear garden contains a duck pond. Current fees at the home range from £420 to £425 per week and additional charges are made for chiropody, hairdressing, toiletries and newspapers. The home’s ‘Statement of Purpose’ and ‘Residents Guide’ is available from the manager and a copy of the most recent Inspection Report is kept in the entrance to the home. Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit took place on a weekday between 11am and 5pm and involved observing care practice (such as medication administration), speaking with residents, staff and visiting relatives and examining records. Discussion was also held with the registered manager and the registered person representing the company who owns the home. All communal areas of the home were seen, together with the majority of residents’ bedrooms. The Pre-Inspection Questionnaire completed by the Registered Manager was not available for review prior to the inspection visit – neither were the two written survey’s returned by relatives. Information from these was taken into account however when writing the Report. The home’s current Statement of Purpose and Service User Guide (these documents outline the home’s services and ethos) were reviewed as part of the inspection process to measure the accuracy of the information provided in these documents against current practice. What the service does well: What has improved since the last inspection? Eleven recommendations for improvement in practice were made at the previous inspection of these, one has been met; staff have now been supplied with the General Social Care Council’s Codes of Conduct. Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 6 Additionally all radiators within the home have been covered to ensure that they do not present a burning risk to vulnerable residents. What they could do better: Information in the Statement of Purpose and Service User Guide needs to be reviewed so that it accurately reflects the services and facilities currently offered by the home. Consideration should also be given to producing the guide in different formats suitable for those with impaired vision or whose first language is not English. Residents or their relatives need to be involved in how their care plans are put together and reviewed and all information about the resident needs to be taken into account as part of the review to make sure that plans are accurate and care is delivered consistently. There are discrepancies in the way medication is administered and what appears on the Medication Administration Record (a similar issue was raised at the previous inspection). The registered person was asked to supply evidence that any changes made to the medication record had been made by a resident’s doctor. Improvement is also needed in monitoring the ongoing competence of staff in correctly administering medication as a staff member had signed for medication several hours before they subsequently observed residents taking that medication. One relative also commented that residents are not consistently observed when taking medication. During the tour of the home several skin creams prescribed for named residents were found in the bedrooms of other residents. There appears to be some discrepancy between the information about activities in the home described in the Statement of Purpose and on the weekly Activity List and those that actually, regularly take place. The registered person must evaluate this and make sure that the activities actually provided take account of the abilities and interests of the people living in the home. Improvements are needed to make sure that meal times are a relaxed and enjoyable highlight of the day. Ways should be explored to make sure that residents are offered a meaningful choice of food and residents’ dependency levels should be monitored to make sure that there are sufficient staff on duty to meet everyone’s needs at this busy time. Some of the place mats used at dining tables were also observed to be worn and shabby and not all of them were cleaned between the lunch and tea-time meal. In several residents’ bedrooms and some communal areas paintwork was badly marked and wallpaper was coming away from the wall; some carpets were also stained and looked worn. Chairs in the lounges were worn and did not offer support for those sitting on them making it difficult for people to get in and out of them. Three relatives commented, unprompted, that they felt the décor in the home was badly in need of improvement. The home was also excessively warm and one resident said that they wanted to turn their radiator down but Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 7 were unable to do so at present. The registered person said that a full refurbishment of the home was due to talk place within the next three months; this would include an upgrade of the central heating system. Although relatives said that they raised any concerns or complaints with the registered person or the manager some were unaware of the home’s formal complaints procedure. Concerns raised verbally and the responses made by the home are not recorded. This means that this information cannot be used as part of the home’s method of measuring and improving quality in the home. This aspect of management needs considerable improvement as there appears to be no systematic system of finding out residents’, relatives’ and other stakeholders’ opinions about how the home is run. There are therefore no clear systems to ensure that quality is maintained and improved and that the home is run in the best interests of its residents. Finally action is required by the registered person to ensure that residents are protected. No staff member should begin work until their name has been checked against the Vulnerable Adults Register and a Criminal Records Bureau check has been obtained. Despite being aware of this Regulation the registered person allowed a staff member to start work at the home without these checks being in place and an application for the checks was not submitted until 12 days after the staff member commenced employment. It is recommended that training be sought from the local authority about local agency protocols concerning the protection of vulnerable adults to make sure that the manager and all key staff are fully aware of their responsibilities in this area. The registered person must also ensure that the Commission is informed of any incident that adversely affects the well-being or safety of a resident. 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. Willows Court DS0000063757.V335966.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 Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is adequate Residents are assessed before they come to live in the home to ensure that their needs can be met. Some information supplied about services and practices is inaccurate; this does not assist prospective residents to make an informed choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence gathered during the inspection visit suggests that many aspects of the Statement of Purpose are not an accurate reflection of the current services and practices in the home. For example no evidence was found that residents or their families were involved in the formulation or review of care plans or that weekly craft and ‘keep fit’ sessions take place. The document also states that the home is non-smoking whereas smoking is permitted in the conservatory area. Some of these discrepancies were raised with the registered person and manager and the importance of accuracy was emphasised as a means of enabling residents to make an informed decision before coming to live in the home. Currently the statement is not an accurate reflection of the services on offer. Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 10 The assessment process for the most recently admitted resident was discussed with the registered manager. This has been an emergency admission but the manager had accessed the care manager’s assessment prior to the person being admitted and this was in place. On two other case files there was evidence of assessment documentation. The manager stated that usually she would assess the person prior to them coming into the home to ensure that their needs could be met. The home does not provide intermediate care. Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate Poor practice in medication administration may compromise residents’ health and wellbeing. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were examined, including one for the most recently admitted resident. Monthly review sheets did not appear to take account of information contained within daily records or observed practice. One resident had been initially identified as being at risk of falls but discussion with the registered manager and examination of daily records indicated that this risk had significantly reduced since the resident had settled into the home. This information was not reflected in the care plan review, neither was there any evidence that residents had been involved in the review process; the registered manager confirmed that they or their relatives were not routinely involved. Care files contained separate health care sheets documenting visits from health professionals including opticians. Residents do not have access to a regular chiropody service (again this is incorrectly stated in the statement of purpose) but staff cut residents’ toenails and check residents’ feet following Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 12 their bath. Certificates were available to evidence that staff had received training in this area. The registered manager stated that if residents wished to access private chiropody this could be arranged and that NHS chiropody was still obtainable for people with diabetes. One resident said that their glasses had been broken for some time and that they were waiting for the optician to visit so that these could be mended. One relative said that the home had contacted GPs when their relative was ill. Several examples of poor practice in relation to medication were found: • The medication round was observed – the medication administration record (MAR) had been signed for three residents before the round started. The person administering the medication had received training in medication administration (indicated by certificates on their staff file) and said that they knew this to be incorrect practice. No system of ongoing monitoring of staff competence is in place and it was recommended to the manager that such a system be implemented. • Three jars of ‘Hydrous Ointment’ prescribed for individual residents were found in the rooms of residents for which they had not been prescribed. One open jar of cream had been supplied in January 2006. This indicates that creams prescribed for residents are not being used in accordance with prescriptions. This issue was raised at the previous inspection. The MAR contained several handwritten changes; for example a sedative, which the MAR showed should be given ‘as required’ was recorded as being given every morning from 23/04/07 until the date of inspection visit. The registered manager explained that the mental health unit “like us to keep her on it” however there was no documentary evidence in place to substantiate this. Another resident’s record showed that one tablet to be administered twice per day was only being administered once per day. A letter was sent following the inspection visit requiring that the registered person ensure that urgent action be taken to ensure that evidence to demonstrate that the residents’ general practitioners (or other doctors involved in their care) had given authority for these alterations. Such evidence should be retained in the home in respect of the residents identified yesterday and for all future changes to any resident’s medication made. • Many residents were unable to express directly if they felt staff treated them with dignity and respect, but the majority of staff interaction with residents was observed to be calm and respectful. It was noted that one staff member communicated effectively with a resident who was hard of hearing by rephrasing the information given to here rather than just repeating it. Three relatives spoke with the inspector. Two spoke positively about the staff and the care received by their relative, one commenting that certain staff had a “heart of gold”. One relative was less positive saying that one staff member Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 13 routinely rushed their relative and that there had been times when they had noticed other residents wearing clothes belonging to their relative. Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate To ensure that residents’ emotional and physical wellbeing is promoted improvements are needed in the type and frequency of activities offered, the way meals are served and choice promoted. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A programme was displayed outlining activities taking place on a daily basis but this does not appear to be an accurate reflection of the type and frequency of activities taking place. Discussion with residents, relatives and the registered manager suggests that activities do not take place regularly within the home but tend to be focussed around celebrations such as Christmas and Easter, for example Easter bonnet making. Music was put on in the afternoon of the inspection and staff sat with residents in one of the lounges and sang along and danced with them No restrictions are placed on visitors and those present during the inspection said that they felt able to come to the home when they wished. Lunch was roast pork with Yorkshire pudding, potatoes and vegetables followed by peach flan and dream topping. The meal itself looked and smelt appetising and residents were observed to eat well although improvements could be made to how the meal is served. Several place mats were very worn Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 15 and some still had dried food on them from a previous meal (this was not removed prior to the meal served at tea time.) Several residents needed assistance to transfer to the table and then required help either with cutting up their food and/or with eating it. The staff available (three care staff and the registered manager) did not appear to be sufficient to meet everyone’s needs and one resident started to eat their food with their fingers because their knife and fork had not been placed within easy reach. Three residents had to wait several minutes before a staff member was available to help cut their meat. At one table it was observed that aprons were being placed on residents after their food had arrived and they were attempting to eat their meal. Another resident expressed concern that the person that they were sitting with would try and eat their meal. The atmosphere in the dining room therefore was not conducive to a relaxed and enjoyable meal. Most residents did not know what was for lunch before the meal was served and it is recommended that ways be explored to ensure that residents are able to make a choice about the food, closer to the time when they will actually eat it. Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate Better promotion of the complaints procedure and more robust recruitment procedures are needed to ensure concerns are listened to and residents are actively protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager was unclear about some aspects of local agency protocols in relation to protection of vulnerable adults and it was recommended that she should seek training from the local authority to clarify this. Evidence that staff members had Criminal Records Bureau (CRB) checks was not available within the home but the registered person agreed to forward this information. An email received on the 14th May 2007 stated that Best Care did not hold this information as the majority of staff had been employed by the previous owners who held this information. The registered person stated that they would obtain and provide the Commission with evidence that all staff members have undergone appropriate CRB checks. The employment records of the most recently recruited staff member showed that although they had started working in the home on 27th November 2006 a Criminal Records Bureau check was not applied for until 08th December 2006. The registered person said that they were aware that no one should start work at the home before their names had been checked against the vulnerable adults register and a CRB check was completed but that staffing levels dictated that this person be employed immediately. Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 17 The registered manager stated that there had been no complaints made to the home since 2003. However discussion with two relatives indicated that complaints and concerns are routinely raised with the manager but no log is kept of these or the response made. Relatives, although aware that they could raise concerns with care staff and/or the manager, seemed unaware of the formal complaints procedure. Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25, 26 Quality in this outcome area is adequate Improvements are needed to the décor and furnishings of the home to ensure that the environment is comfortable and pleasant to live in and suited to the needs of the people living there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During a tour of all communal areas and the majority of residents’ bedrooms it was noted that in several areas wallpaper was peeling from walls, ceilings were stained and paintwork was badly marked. Carpets in several residents’ rooms were stained and worn and chairs in the lounges were also worn offering little support to those using them. Discussion with the registered person indicated that a system was in place to ensure ongoing maintenance but one resident’s bedroom had been without hot water for some time the flush on a toilet near to their room was also not working. Two relatives spoken with directly and the two comment cards received stated that the home needed new furnishings and that decoration needed should be updated and improved. The registered person agreed with this and said that a Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 19 programme of complete refurbishment was planned within the next three months. When refurbishing the home the needs and preferences of the people living in the home should be actively considered. Quotes are also being obtained to update the home’s heating system as many areas of the home are excessively warm (including some residents’ bedrooms) and the temperature of these cannot currently be controlled. All radiators in the home have been covered. Generally the home was tidy and fresh smelling - one relative commented that the home was usually clean and didn’t smell of urine. However cleaning in the dining area does require improvement – to ensure that place mats (however worn) are cleaned between meals. Willows Court DS0000063757.V335966.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): 27,28,29,30 Quality in this outcome area is adequate Improvements must be made in recruitment practices and the monitoring of staffing levels and competence, to ensure that residents’ are consistently well supported and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The rota showed three care staff on duty for each shift although the current statement of purpose states that there will be at least six. There are currently only twenty residents living in the home but the registered person should review dependency levels to ensure that sufficient staff are on duty to meet resident’ needs at all times (please see also Daily life and Social Activities). Good arrangements are in place for staff to achieve National Vocational Qualifications (NVQs) with four staff members having completed level 2 in care and one level 3; two staff members hold qualifications in general nursing. The cook is undertaking a NVQ in catering and the manager is investigating a similar qualification in housekeeping for domestic workers. Certificates and course materials suggest that staff have received training in such areas as dementia care with the registered manager undertaking such training alongside staff; this is good practice. However mechanisms to ensure that training is implemented need to be improved (See Health and Personal Care). Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 21 The employment records of the most recently recruited staff member together with two staff members on duty were examined. All contained proof of identity, two written references, full employment history and details of qualifications and training. The most recently appointed staff member started work at the home before a Criminal Records Bureau check had been applied for and before their name had been checked against the Vulnerable Adults Register (please see also Complaints and Protection). Willows Court DS0000063757.V335966.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): 31, 33, 35, 38 Quality in this outcome area is adequate Management systems to monitor and improve quality in the home are insufficient to ensure that the home is run in residents’ best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has been in post for several years and has recently submitted her portfolio for The Registered Manager’s Award. A record was seen of conversations held by the registered manager with residents about suggestions for improvements to the home. The registered person said he sent questionnaires to relatives asking for their comments on how the home was run but two relatives spoken with said that they had not received a questionnaire, neither had the registered manager seen any results from any surveys. Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 23 The Registered Manager stated that the home had no involvement in managing residents’ monies. Expenditure on behalf of residents could be made from the petty cash system and then relatives invoiced later. Records showed that fire extinguishers and systems had been regularly serviced and that fire practices took place in the home approximately four times per year; a fire risk assessment was also in place. The home’s passenger lift is serviced four times per year under contract but the hoists used in the home only once per year; these should be serviced every 6 months. The registered person stated that he would ensure that the Contract was modified to ensure this was done. The Accident Record showed that some falls, where residents had sustained an injury, had not been notified to the Commission, which the registered person is required to do. Willows Court DS0000063757.V335966.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 1 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X X X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 2 Willows Court DS0000063757.V335966.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 OP1 Regulation 4 Requirement Timescale for action 31/07/07 2 OP7 15 3 OP9 13 The statement of purpose must be comprehensively reviewed to ensure that it accurately reflects the facilities and services provided by the home to enable prospective residents to make an informed decision. 31/07/07 Care plans should be regularly reviewed with all relevant information (including contributions from the resident and/or their representative) being considered as part of that process. This is to ensure that care plans continue to be an accurate reflection of care required and that care is delivered in a consistent manner. All medication (including creams 31/05/07 and ointments) must be administered to residents according to the directions given by the person prescribing the medication and in accordance with directions on the Medication Administration Record. This is to ensure that all residents receive the correct medication at the correct time to maintain their physical and mental health. DS0000063757.V335966.R01.S.doc Version 5.2 Willows Court Page 26 4 OP9 13 5 OP9 13 6 OP12 16 (2) (n) 7 OP18 19 (1) (b) 8 OP33 24 9 OP38 37 (1) (c)(e) The Medication Administration Record must only be signed after the person administering medication has directly observed the person has taken their medication. This is to ensure that the record of medication received is accurate. Evidence from the prescribing physician must be obtained and retained for any changes made to the Medication Administration Record. This is to ensure that any changes made to the record have been authorised by a medical practitioner. Activities must be regularly provided for residents that take account of their abilities and interests to maintain and promote their physical and emotional wellbeing. An enhanced criminal records bureau check must be obtained for all new staff members and their names checked against the Protection of Vulnerable Adults register before they start work in the home. This is to ensure that unsuitable people do not have access to vulnerable people. A system to evaluate the quality of the service, which involves regular and ongoing consultation with residents, their relatives and /or their representatives must be put in place. This is to ensure that the service is run in the best interests of the residents that live there. The registered person must notify the Commission, without delay of the occurrence of any serious injury to a resident and any event that adversely affects the well-being or safety of a resident. DS0000063757.V335966.R01.S.doc 09/05/07 31/05/07 31/07/07 09/05/07 31/05/07 09/05/07 Willows Court Version 5.2 Page 27 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 2 3 4 Refer to Standard OP1 OP9 OP15 OP15 Good Practice Recommendations Consideration should be given to producing the ‘Service Users’ Guide’ in different formats suitable for those people with limited vision or whose first language is not English. Systems should be implemented to ensure the ongoing competence of staff in administering medication. The registered person should explore ways in which residents may be given a meaningful choice with regards to food at mealtimes. Residents’ dependency levels should be kept under review to ensure that sufficient staff are on duty to meet their needs at peak times of activity such as meal times. (This recommendation was made at the previous inspection) A record should be kept of all complaints and concerns raised by residents, relatives or other interested stakeholders. This should include the date of and nature of the response made. Efforts should be made to ensure that residents and their relatives are aware of the home’s formal Complaints Procedure. The registered manager should seek training from the local authority to clarify local agency protocols in relation to protection of vulnerable adults. The planned refurbishment should take into consideration the needs and preferences of the people living in the home. 5 OP16 6 7 8 OP16 OP18 OP19 Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Willows Court DS0000063757.V335966.R01.S.doc Version 5.2 Page 29 - 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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