Inspection on 11/05/07 for The Willows

This inspection was carried out on 11th May 2007.

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

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

Other inspections for this house

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

CARE HOME ADULTS 18-65 Willows, The 4 & 5 Sadler Gardens Coalpit Fields Road Bedworth Warwickshire CV12 9HG Lead Inspector Justine Poulton Key Unannounced Inspection 11th May 2007 11:30 Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 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, The DS0000068556.V339447.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 Adults 18-65. 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, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willows, The Address 4 & 5 Sadler Gardens Coalpit Fields Road Bedworth Warwickshire CV12 9HG 0247 6315794 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) Coventry and Warwickshire Partnership Trust Glynis Joyce Goldswain Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide care and accommodation for seven service users under 65 for reasons of learning disability. N/A6 Date of last inspection Brief Description of the Service: 4/5 Sadler Gardens, known as The Willows, is a purpose-built, large, semi detached pair of bungalows. The home was built to accommodate seven service users with learning disabilities and additional physical disabilities. The home has recently reregistered under Coventry and Warwickshire Partnership Trust and is staffed 24 hours a day. The premises are leased from a local housing association. The bungalows are linked internally via a connecting door in the main halllways. Single room accommodation is provided, with up to three service users accommodated in number four and up to four in number five. Each bungalow has laid out gardens to the side and rear, which are fenced around the perimeter. The home is situated in a housing estate approximately half a mile from the centre of Bedworth, North Warwickshire. A local bus service stops nearby and the shops and amenities of the town centre are within walking distance. Two speciality vehicles are available to provide transport for the people living at the home. The fee for this home was recorded as £445.69 per week in the pre inspection questionnaire received prior to the inspection. Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the first key inspection of this service following reregistration with Coventry and Warwickshire Partnership Trust. The inspection was carried out to establish the outcomes for people living in the home, and to confirm whether they are protected from harm. Identified key standards were looked at. The pre fieldwork documentation was completed, as well as a site visit to the home, during which time staff, service users and the manager were spoken with. Two people were identified for close examination by reading their care plans, risk assessments, daily records and other relevant information. This is part of a process known as ‘case tracking’ where evidence is matched to outcomes for service users. Records, policies and procedures were examined and the environment was looked at. All of the people who live in the home were in for all or part of the inspection. The inspector would like to thank the service users, manager and staff for their hospitality and co-operation during the inspection. The home had one vacancy at the time of the inspection. What the service does well: The home consistently meets the key national minimum standards ensuring positive outcomes for the people who live there. The home presented with a very relaxed atmosphere. Staff appeared confident and competent in their roles, and were careful to ensure that peoples needs and wants were met. Peoples care plans reflect their assessed needs. They are detailed and informative, ensuring that staff are able to support them appropriately. Comprehensive risk assessments enable people to take meaningful risks in a safe manner. People are actively supported to make decisions about their lives both on a daily and more long term basis by staff who work hard at ensuring that they are able to recognise and interpret peoples limited verbal and non verbal communication skills. People are supported with their interests, hobbies, leisure pursuits and with planning holidays. Day services are provided by the home during the week. These are varied and reflective of indivuals likes and dislikes. The involvement of families and friends is important to people, and is encouraged by the home. Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 6 Clean, tidy, well stocked kitchens enable people to choose from a range of meal options. Support with any special diets and assistance with eating is provided as required. The people who live in this home have their personal care needs provided sensitively and discreetly by staff in line with their assessed needs. Their health and wellbeing is also promoted via attendance at routine and more specialized healthcare appointments as necessary. Medication is managed safely on their behalf. The home has both a complaints policy and an adult protection policy in place. Staff were aware of how people with limited verbal communication make their needs known. At the time of this inspection no complaints had been received by us. Staff were aware of their responsibilities regarding adult abuse, as was the manager who was able to relay the actions taken in relation to an incidence of whistleblowing by staff recently. The home was found to be comfortable and clean with no offensive odours apparent. It was decorated nicely with good quality furniture and soft furnishings. Staff numbers were satisfactory based on the current number of people resident in the home. Training undertaken by the staff team ensures that a competent and sufficiently knowledgeable team supports them. The home is managed by a competent manager with whom both the residents and staff team appeared to have a good rapport. Health and safety is managed effectively within the home. What has improved since the last inspection? What they could do better: Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 7 No requirements have been made in this report. 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, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Quality in this outcome area is good. Suitable and appropriate information to help prospective residents (and their representatives) to decide if the home is the kind of place they would like to live in is available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although this is the first inspection of this service following registration with us under Coventry and Warwickshire Partnership Trust, it has actually been in existence for a considerable number of years with a stable resident group. The homes Statement of Purpose was looked at as part of the inspection. This document clearly identified the levels of service that could be offered to specific user groups. It was detailed, informative and reflective of the actual service being provided. As there have been no new service users admitted recently the pre assessment process was not examined as part of this inspection. It must be noted that the home had one vacancy at the time of the inspection. Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is excellent. Peoples needs are well documented and reviewed so that staff are able to provide them with the support they require, in the manner they prefer it. Detailed risk assessments that support people to live full lives in a safe manner are also in place. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of this inspection two people were chosen for case tracking purposes. All of their care planning, health, medication, daily diaries and day service documentation was looked at. Both care plans followed a person centred format and were written in the first person, thus providing a sense of ownership with the people they were for. Both plans followed a similar pattern, providing information about such things as individual needs, preferred routines, likes and dislikes, communication and Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 11 abilities amongst others. The required levels of support were detailed, thus enabling staff to provide appropriate assistance and care for each person. Information was available to confirm that the care plans get reviewed as routine on a six monthly basis and updated as necessary. As well as comprehensive care planning documentation each person had a mixture of generic and individual risk assessments in their files. The generic assessments included such things as financial abuse, inadequate staffing levels and unmanaged health issues. Individual assessments related more to choking, having a seizure and falling. Again, information was clearly available to confirm that the risk assessments are reviewed on a regular basis and updated as necessary. All of the people that live in the home have limited or no verbal communication skills, however it was apparent throughout the inspection that the staff were able to interpret their individual means of communication and ensure that they were involved in making decisions about their lives. The manager said that at the time of the inspection one person was going through a process of choosing which of the two bungalows to live in. This was being facilitated by the staff team, who were enabling this person to make decisions about where to spend their time within the two properties. Staff were also able to explain peoples observed behaviours and responses to situations and offer suggestions as to how best to approach people so as not to cause them anxiety. Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is excellent. People are offered a variety of age, peer and culturally appropriate activities that make best use of in house and community facilities. Relationships with families and friends are promoted. A healthy, nutritious diet is provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the people resident in the home have their day services provided in house. Each person has a separate individual day time activities file. The two day service files looked at as part of this inspection were extremely detailed. Information available included the weekly timetable, along with an explanation of each activity or outing. Information on each session contained photographs and any identified outcomes for the person taking part. As well as these a session monitoring form was also available which is completed by staff Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 13 after each activity. Each person participates in day service activities for four days each week, in such things as swimming, bowling, a local nostalgia club, sensory sessions, visits to a local park and café and watching dvd’s or listening to music. During the inspection three of the people living at the home were out participating in their day service. As well as their formal day service provision, each person also had an evening and weekend activity plan in place. As staff arrived on duty for the afternoon shift they were linked to a person for the shift and were heard to be discussing the afternoon / evenings planned activities with them. As two people had been out bowling during the day, an alternative to the evenings planned activity, which was also bowling, was being suggested. As previously recorded, the people resident in the home have limited or no verbal communication, therefore the staff are relied on to assist and support them with maintaining any personal relationships with relatives and friends. These relationships are seen as being of prime importance by the home, and are facilitated as appropriate. The home welcomes visitors and ensures that they are introduced to the people living there as they arrive. As the home is made up of two separate bungalows connected via an internal door they are generally treated a two separate provisions. However, the manager said that as there are only five people resident at the time of the inspection, mealtimes were being shared rather than being held separately. A weekly menu is planned by the staff and people living in the service. This was being undertaken during the inspection. It was pleasing to note that although the people resident in the service were unable to voice their opinions with regards to meal choices, staff were including them in the discussions, and ensured that a favourite meal of each person was included in the menu. As well as the weekly menu, each person has a record chart of meals and foods eaten. Both the suggested menu and records of foods eaten confirmed that a healthy and nutritious diet is offered that reflects individual likes and preferences. Both of the kitchens were clean and tidy on the day of the inspection. They were domestic in both size and functionality, well stocked, and had the necessary checks and records in place. One person is provided with the necessary nutritional intake via a nasogastric tube. Although this person was not one of the two chosen for case tracking purposes, staff spoken with said that they had received training on how to deliver food in this manner, and copies of training certificates were seen within staff files looked at. The manager said that the community nurses were responsible for providing staff training in this area, and for monitoring and overseeing the nutritional intake of the person concerned. Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. People who live in the home receive personal support in line with their assessed needs. Their healthcare needs are monitored and addressed. Medication is managed safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As previously recorded the people who live in this home have separate personal files that contain information about their personal care and health care needs. The levels of personal care and support required by people are also detailed within their care plans and ensure that staff are able to provide the necessary levels of assistance as directed by their assessed needs. Information available within the two personal files looked at confirmed that people are supported with their healthcare as necessary. Records of attendance at the routine healthcare appointments such as the dentist, opticians at the recommended intervals, along with and GP appointments were recorded, as were attendance at more specialist appointments and clinics such as with a dietician, psychologist, speech and language therapist, urology clinic, Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 15 breast screening clinic and the chiropodist. The outcomes of all healthcare appointments were clearly recorded, and any actions required were undertaken. None of the people living in the home currently administer their own medication. Instead they rely on the staff team to undertake this for them. Medication is provided by a local chemist, and is accompanied by medication administration record charts. Staff spoken with said that this is the first month medication has been supplied by this pharmacy, as it was previously provided from elsewhere, but they feel that it is a clearer system. Guidelines for staff administering medication to people unable to give verbal consent were available within the two files looked at, as were protocols for medication rejected or damaged, the administration of ‘as and when’ paracetomol, the administration of ‘as and when’ rectal valium and the administration of ‘as and when’ cream for eczema. Separate recording charts for ‘as and when’ medication were also in place. Staff said that they are not allowed to administer medication until they have received training in this area. This was confirmed by one member of staff new to the home, and currently on induction. Training records available indicated which staff had received training in the administration of medication. The manager also said that all staff were to undergo training from the new medication provider in the near future on their multi dispensing systems. On the day of the inspection medication records for the two people being case tracked provided no cause for concern. Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. The homes policies on complaints and protection from abuse ensure that peoples views are listened to and acted upon, and that they are safeguarded from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The organisation has provided the people who live in the home with copies of the complaints information and procedure. This is written using pictures, symbols and text, in an effort to make it accessible for them. Each person had a copy in their personal files. At the time of writing this report no complaints had been received by the home or us. The home also has a policy on the protection of adults from abuse in place. Previously received notifications under regulation 37 regarding allegations against two staff members were discussed with the manager, who was able to talk through the processes that were undertaken with regards to these, and the outcomes. Staff spoken with were clear about what they would do in the event of abuse being suspected or disclosed. Information provided in the pre inspection questionnaire received prior to the inspection indicates that the manager of the home is the financial appointee for four of the people who live there. Clear audit trails and financial management guidelines were in place for individual personal spending monies. Each person’s money is checked on a daily basis, and two members of staff are required to Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 17 sign for each transaction undertaken. Monies checked during the inspection tallied with balances recorded and receipts available. Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is excellent. The appearance of this home creates a pleasant, comfortable and homely environment that is well maintained. The home presents as clean and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registration for this home covers both numbers 4 and 5 Sadler Gardens. These are a pair of semi detached bungalows that are connected via an internal door in a hallway between the two. The décor throughout both properties was immaculate, with very good quality soft furnishings and modern furniture. Peoples bedrooms looked at were seen to be decorated to individual taste with plenty of personalisation in the form of pictures, photos and ornaments. Although the bungalows are leased from Bromford Corinthia Housing Association, the manager said that any maintenance issues are undertaken by the trusts maintenance department. Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 19 Each bungalow has a separate utility room, that house the washing machines and tumble driers. Cleaning products are also kept in these rooms in locked cupboards. Risk assessments relating to cleaning products were in place, as were the appropriate Control of Substances Hazardous to Health (COSHH) data sheets. On the day of the inspection the bungalows were clean and hygienic, tidy and free from offensive odours. Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. People who live in this home benefit from sufficient numbers of competent, knowledgeable staff. Recruitment practices ensure that they are safeguarded from potential harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided in the pre inspection questionnaire received prior to this inspection indicated that 23 staff including the manager are employed to work at the home. Copies of rota’s provided indicated that each bungalow is staffed separately, with either two or three staff on duty in each for each shift. In addition four staff for each bungalow are also on duty each day to provide day services from Monday to Friday. At the weekends rotas indicate that there are between two and four staff on duty. The numbers of staff available to support the people living in this home are sufficient to meet their assessed needs. This reflects the fact that the home currently has five instead of seven residents. A number of staff have commenced employment in the home since the last inspection in 2005. The records of four of these were checked during the Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 21 inspection. These confirmed that that appropriate vetting checks are carried out prior to people commencing work, that include Criminal Record Bureau checks and a minimum of two references. Staff training records were also checked as part of this inspection. These confirmed that staff are on a rolling programme with regards to their mandatory training. New staff spoken with advised of what training they had undertaken as part of their induction, and what was planned. All staff are registered on the learning Disability Awards Framework induction and foundation programmes, and were overheard to be discussing this in a positive way between themselves. As well as the mandatory subjects such as first aid, fire safety and moving and handling staff also receive training in vulnerable adults, medication administration, equality and diversity and nasogastric tube feeding and pump use. According to the pre inspection questionnaire 42 of staff have achieved their NVQ II or above. This was confirmed during the inspection. Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. A suitably qualified management team is in place at the home so that the people who live there benefit from a well-run service. The implementation of the proposed quality audit system will ensure that the people who live in this home are at the forefront of service provision and development. Health and safety is managed appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home continues to be run by a well-qualified manager who holds many years experience of working with people with learning disabilities. The management team at the home also includes two well-trained and experienced group leaders. Comments made by staff during the inspection confirmed that they feel respected by the manager, and able to raise any issues or concerns Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 23 with her. It was stated that she has an open door style of management and is very supportive of the team. During the inspection the manager was working on the homes quality audit plan for 2007. As the home has recently undergone a change of provider, the manager stated that this plan is to be implemented in the near future and will include systems to meaningfully include the people who live in the service with expressing their views about the quality of provision they receive. A copy of the quality audit plan was provided for information as part of the inspection. Information provided within the pre inspection questionnaire identified when the necessary maintenance checks and procedures were last carried out. A sample of these that included the gas safety certificates, portable appliance testing, the water temperature records for the bedrooms and fire safety records confirmed that these are all undertaken at the required intervals, thus maintaining the health and safety of all who live in, work in or visit the home. Willows, The DS0000068556.V339447.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 Adults 18-65 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 3 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 4 x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 25 N/A Are there any outstanding requirements from the last inspection? 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. Refer to Standard Good Practice Recommendations Willows, The DS0000068556.V339447.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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, The DS0000068556.V339447.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!