Inspection on 14/09/09 for Willows The

This inspection was carried out on 14th September 2009.

CQC 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 CQC judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Willows The 17/09/08

Willows The 19/09/07

Willows The 28/09/06

Willows The 01/02/06

Willows The 08/12/05

Willows The 22/11/04

Willows The 14/07/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Willows The Bridlington Road Burton Fleming East Yorkshire YO25 3PE Lead Inspector Sarah Rodmell Key Unannounced Inspection 14th September 2009 09:30 DS0000029969.V377668.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Willows The DS0000029969.V377668.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Willows The DS0000029969.V377668.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willows The Address Bridlington Road Burton Fleming East Yorkshire YO25 3PE 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) 01262 470217 01262 470217 Hexon Limited Vacant Care Home 33 Category(ies) of Dementia (33), Old age, not falling within any registration, with number other category (33) of places Willows The DS0000029969.V377668.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE The maximum number of service users who can be accommodated is: 33 17th September 2008 2. Date of last inspection Brief Description of the Service: The Willows is a two-storey building offering personal care and accommodation to 33 older people who may have a dementia. There is a designated area for people with dementia. A two-storey extension has been added to the main building and provides pleasant airy en suite rooms. The home provides communal dining and lounge space and gardens to the rear. There is car parking space to the front of the home. Information about the services available at The Willows is provided to prospective service users and their families in the form of a brochure. The home’s statement of purpose is available at the home along with the most recent inspection report. Willows The DS0000029969.V377668.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 1 star. This means that the people who use the service experience adequate quality outcomes. This inspection report is based on information received by the Care Quality Commission (CQC) since the last key inspection on 17 September 2008, including information gathered during a site visit to the home. The unannounced visit was undertaken over one day by one inspector. It began at 9.30 am and finished at 4.00 pm. On the day of the visit the inspector spoke with people who live in the home, staff, the manager and area manager of the home. Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The manager submitted information about the service in the Annual Quality Assurance Assessment form (AQAA) to the CQC from the home. The AQAA is a self assessment tool that focuses on how well outcomes are being met for people who use the service. The manager told us that the current fee for residential care is £374- £420 per week. At the end of this visit, feedback was given to the manager and the area manager on our findings, including any requirements and recommendations that may be in the key inspection report. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: People’s needs are assessed before they move into the home to help make sure that the care staff are aware of these and to confirm that they have the skills and experience to be able to meet them. People’s needs are met in a manner that upholds their dignity. Willows The DS0000029969.V377668.R01.S.doc Version 5.2 Page 6 People are happy with the standard of the food provided. There are systems in place for supporting people with their monies, which are clear and well organised. What has improved since the last inspection? What they could do better: People should be involved in the development and review of their care plan, so that they can make decisions and influence the care that they receive. Risk assessments and monitoring forms should be used consistently to ensure that staff are aware of the latest needs of everyone who lives in the home. The quality assurance systems could be further developed to include other stakeholders, developing a more comprehensive picture. Willows The DS0000029969.V377668.R01.S.doc Version 5.2 Page 7 The manager should be registered with the CQC. Staff disciplinary actions should be reported to the CQC as per the requirements, to make sure that an up to date picture can be held. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Willows The DS0000029969.V377668.R01.S.doc Version 5.3 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 The DS0000029969.V377668.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not assessed as there is no intermediate care. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their needs assessed prior to moving into the home to ensure that these can be met. EVIDENCE: We examined the care files of three people who live in the home. These files all included a pre-admission assessment based upon the activities of daily living. This provides the staff in the home with a picture of the individual’s needs prior to them moving into the home, so that they know what care they will require Willows The DS0000029969.V377668.R01.S.doc Version 5.3 Page 10 and whether the staff have the skills and training to be able to provide that care. The manager confirmed in the AQAA that everyone is admitted to the home on a 4 week trial basis, allowing them the opportunity to try out the home. We observed rooms that have been prepared for new people to move into, and that these included an information pack on living in the home. The manager confirmed to us that the home does not provide intermediate care. Willows The DS0000029969.V377668.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported with their needs in a dignified way through a care planning approach. Howeve,r inconsistencies in recording may reduce the effectiveness of these. EVIDENCE: Of the three individual files that we examined, all included a plan of care. This detailed the needs of each individual and how these were to be met. We found that these were regularly reviewed in the home. However, there was little evidence of the involvement of individuals in the development or review of their care plan. This would ensure that they were aware of and agreed to its content. Willows The DS0000029969.V377668.R01.S.doc Version 5.3 Page 12 The manager wrote in the AQAA that the new care plans are very ‘in depth’ and that they had been adapted to meet the needs of the service user. We found that the care plans covered a variety of areas including safety, communication, diet and fluid intake, mobilising, personal hygiene and social care. Risk assessments were also in place, alongside monitoring forms. However, we found that although forms were in place, on occasions they were not always used. For example, only one person had a ‘ Getting to know you’ form. This form provided good information about the person prior to them entering the home and helped the staff understand them as an individual. There were records of visits from professionals and the outcomes of the visits. One person did not have their weight record completed and one person although they had a history of falling in their care plan there, was not a risk assessment for falls completed. Without a consistent approach to these assessments, the staff in the home cannot be sure that they have a complete picture of the needs of the individual and that these are being met. A previous complaint to the home was regarding meeting the needs of people when they are unwell. It was found that record keeping and staff training required improving in these areas and the home has taken actions to remedy this. This includes the introduction of a handover book to make sure that information is not forgotten or missed. The administration of medication was observed during the visit. This was completed in a personal way, with people being asked if they required any of their additional prescribed medicines, such as paracetomol. The medication trolley was kept locked at any time when the person completing the administration was called away. When the medication administration was finished the trolley was suitably locked away. A list of staff signatures is kept for those staff able to administer medication. This provides information for any audit trails that may be required. The records for the administration of medicines were examined and these appeared correct. In addition, records of medicines received and disposed of from the home were also kept. There was no hand written entries on the MAR charts. There is a separate area for the storage of medicines which may be described as ‘controlled’, with a Controlled drugs book in place for the correct recording of these medicines. None were currently in use in the home at the time of this visit. The information provided in the AQAA included that staff have been trained in medication and that there is a monthly medication audit. The area manager Willows The DS0000029969.V377668.R01.S.doc Version 5.3 Page 13 also confirmed that staff had been trained in all areas. Of the files we examined, no evidence was available of this training. We observed that people were well dressed and that their appearances reflected their individual personalities. With some of the ladies appeared to have had their hair blow dried. We noted that when someone needed additional assistance with continence and personal care, this was done in a manner that helped this person maintain their dignity. People’s files included the details of the name that they prefer to be known by and the manager confirmed to us that the use of commodes or bath chairs for moving people around the home has ceased. Two people have their own telephone installed in their rooms and the manager told us that people are able to use the ‘office’ phone as this is a hands free phone. Willows The DS0000029969.V377668.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive visitors, have their interests recorded and receive a good diet. However opportunities for leisure activities are limited. EVIDENCE: Information in the AQAA recorded, ‘We promote and help maintain family contacts, whilst encouraging new friendships in the home’. During the visit to the home we saw that visitors were able to call in and stay as long as they wished. Information in people’s files included their leisure activities and one person had a ‘Getting to know you’ form completed. This aided staff to know more about this person and their past life. It would be recommended that this is completed Willows The DS0000029969.V377668.R01.S.doc Version 5.3 Page 15 for all people who live in the home so that staff can have a full picture of each person individually. This will assist staff with options to consider when arranging activities. The manager informed us that the home accesses a motivation team, which includes a therapist for activities. There are also singers and an organ player who visit the home. People’s personal files included details of the activities that they undertook, including time with their key worker, although one persons’ section for this was not completed. During the visit we observed that people were either relaxing in the lounge or in their own room. No therapeutic activities or entertainment was observed during this time. People’s notes recorded different activities that they had undertaken, although these were limited and mainly key worker activities in the home. People were observed to be able to decide when to be with others or on their own. Some people remained in their room with the door open. People are able to bring personal items into the home and to decorate their room accordingly. Information was available in the entrance to the home about advocacy services; these may support people with the choices they have to make whilst residing in the home. We observed that the lunchtime meal was appetising; all confirmed that the food was good. People are offered choices and the manager has recently introduced a new menu. The menu is positioned at the entrance to the dining room, giving a ‘restaurant’ feel. The menu is not available in other formats, for example, in large print for those with poor eyesight and it is recommended that the home develop this further. The manager confirmed that the requirements of the Local Environmental Health Officer had been met and that a new cooker had been purchased for the home. Willows The DS0000029969.V377668.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies and procedures are in place and followed by staff to help people raise concerns and to assist in protecting them from harm, however the absence of robust risk assessment may place people at the risk of harm. EVIDENCE: Information in the AQAA included that complaints are logged in the complaints file. We examined this and found that there had been one complaint for which the outcome had yet to be recorded. This complaint had been referred through the Local Authority’s Safeguarding Adults procedure and the home had attended meetings to work with the Authority over this. Some actions, for example, the establishing of a ‘handover’ book, had already taken place in response to this complaint. There had been one safeguarding incident that had not been reported via the Local Authority’s Safeguarding Adults Policy; this was prior to the current manager working in the home and was discussed with the new manager, who is aware of the necessity for reporting such incidents. Willows The DS0000029969.V377668.R01.S.doc Version 5.3 Page 17 The AQAA included that staff had been trained in Safeguarding Adults from abuse, and that there is a policy available for this that was reviewed this year. We found that staff recruitment included the obtaining of a Criminal Records Bureau check (CRB) and a Protection of Vulnerable Adults (POVA) first check, to help make sure that people were suitable to work with vulnerable people. Willows The DS0000029969.V377668.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is clean and comfortable, however attention needs to be given to ensure that risks need to be identified and minimised to ensure people are kept safe. EVIDENCE: We completed a tour of the premises and found that on the whole the home appears well maintained and is clean and tidy. People’s rooms were Willows The DS0000029969.V377668.R01.S.doc Version 5.3 Page 19 comfortable and reflected their individual personalities and lives. New lighting has been installed in corridors to improve the environment. Routine maintenance for fire checks was undertaken at the time of the visit. We found that not all of the windows in the home had opening restrictors that would help keep people safe from falls whilst meeting the requirements of the fire authority. The manager was advised that assessment of this should be completed regarding the risks involved and that appropriate actions should be taken. The manager confirmed via email that following the visit, all the windows in the home now have window opening restrictors. We found that the hot water in one bathroom was 53°centigrade and posed a risk of scalding to people in the home. The area manager and manager actioned this on the day of the visit and confirmed that a plumber was to visit that tea time. They advised that work would be undertaken to ensure the correct hot water temperatures and that people would be safe. It was requested that this be confirmed in writing to the CQC the following day. This was received later in the week. The laundry room is at the rear of the property.The walls to this are of brick construction and the manager was advised of the necessity to ensure these are not permeable, as this may contradict the procedures that they follow in the control of infection. Willows The DS0000029969.V377668.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, & 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by staff who are on the whole are well recruited and who receive training, although records of training undertaken by staff need to improve. EVIDENCE: We examined the files of three of the staff. One of these was for someone who had only recently commenced employment in the home. We found the information in the files reflected that good recruitment procedures are followed. People complete application forms, attend interviews and then CRB checks and references are obtained. When it is not possible to obtain two references from previous employers, for example when someone has been self employed, the manager obtains a character reference for the person concerned. One staff member had ceased to work in the home and later returned, and a new CRB check had been undertaken. However, new references were not obtained and the manager was advised as to the necessity for this. Willows The DS0000029969.V377668.R01.S.doc Version 5.3 Page 21 The AQAA included that one staff member has completed their induction that meets with the Skills for Care requirements. A staff member also confirmed to us that they were in the process of completing this. Duty rotas reflected that there are different numbers of staff on duty at different times of the day. This helps to meet people’s needs at busy times, for example, at breakfast time. Staff files included details that people had undertaken training for Safeguarding Adults, Fire drills, Use of the Hoist, MRSA, Dementia care and Food Hygiene. The staff training matrix included a large amount of gaps in staff training. However, the area manager confirmed that this was a list of training needed only to update staff and that all staff had already been trained in all areas, this included Moving and Handling and Medication training. Willows The DS0000029969.V377668.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is comfortable; they are looked after by adequate numbers of staff who are in general well trained. However some shortfalls in the management of the home mean that people may not be protected from the risk of harm. EVIDENCE: The manager is new to the home and is not yet registered with the CQC. She informed us that she has 10 years previous experience in a management of care role. She confirmed that she holds the Registered Managers Award and a Willows The DS0000029969.V377668.R01.S.doc Version 5.3 Page 23 City and Guilds 352/3 qualification. She said that she has recently attended Moving and Handling and Diabetes training. However some aspects of the home are not being well managed for example risks assessments and the maintenance of the home. This service was assessed at the last key inspection as adequate and although some improvements have been made others have not been maintained. People are not being kept safe from the risk of harm. The Quality Assurance folder included relatives questionnaires for 2009.There were catering questions and information that service user meetings are held every 6 months. The manager stated that staff meetings are held monthly. The Quality Assurance system does not reflect the views of all stakeholders and it is recommended that the system be adapted to include others, for example, health professionals. The area manager agreed to forward a copy of the latest published quality assurance report to the CQC. However, this was not received. Disciplinary action had been taken against a member of staff, and the area manager stated that the disciplinary action had later been removed from the persons’ records; however, at the time it was issued it was not reported to the CQC. People are supported with their finances in the home. We found that clear records are kept of expenditure, with receipts obtained and there is secure storage. As this is not in a safe the management may wish to reconsider this. The current practice does not include for a second person to routinely check these records and sign to confirm that they are correct and it is recommended that this takes place. There were records in the home that included a fire risk assessment and safety checks for the prevention of fire, with some checks being undertaken at the time of the visit. Maintenance records are also kept for the electrical systems and lifting equipment in the home. Records are kept of all accidents in the home, providing information and an audit trail. Willows The DS0000029969.V377668.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 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 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Willows The DS0000029969.V377668.R01.S.doc Version 5.3 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP8 Regulation 13 Requirement Timescale for action 14/12/09 2 OP8 17 3 4. OP9 17 16 (2) (m,n) OP12 OP14 5 OP26 13 Assessments must be undertaken to identify risks to individuals and the actions that must be taken to reduce this risk. For example the risk of falls. Forms used to record information 30/10/09 that would support people with their health needs should be used consistently to help make sure that people’s health needs are met. Evidence that staff have been 30/10/09 trained in the handling of medication should be kept. People must be provided with a 14/12/09 range of activities that meet their diverse needs. Previous timescale of 17/11/08 not met. The walls of the laundry room, must meet current requirements in the control of infection. People must not be placed at an increased risk of infection. There must be up to date and full records of staff training. The registered person must ensure that any disciplinary DS0000029969.V377668.R01.S.doc 14/12/09 6 7 OP30 OP33 17 37 14/11/09 30/10/09 Willows The Version 5.3 Page 26 8 OP38 13 action is reported to the CQC. Risks within the home must be identified and managed to reduce the possibility of harm to people. For example the risks from hot water. 30/10/09 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 5 6 7 8 Refer to Standard OP3 OP8 OP9 OP15 OP29 OP31 OP33 OP34 Good Practice Recommendations People must be involved in the development and review of their care plan, allowing them to influence how their needs are met. People should have their nutritional needs assessed. This will help staff know if they are underweight or overweight. Evidence that staff have been trained in the handling of medicines should be kept. Menus should be available in different formats so that these can be accessed by everyone. The registered person must take up new references when an employee rejoins the home. The manager should be registered with the CQC. The quality assurance systems should include all stakeholders. Audits of monies kept in the home should be signed by a second person. Willows The DS0000029969.V377668.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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