Inspection on 17/09/08 for Willows The

This inspection was carried out on 17th September 2008.

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

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

Other inspections for this house

Willows The 14/09/09

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 09/11/2008.

CARE HOMES FOR OLDER PEOPLE Willows The The Willows Bridlington Road Burton Fleming East Yorkshire YO25 3PE Lead Inspector Jo Bell Key Unannounced Inspection 17th September 2008 10:15 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 The DS0000029969.V372106.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 The DS0000029969.V372106.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willows The Address The Willows Bridlington Road Burton Fleming East Yorkshire YO25 3PE 01262 470217 01262 470217 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) Hexon Limited Amanda Jayne Warkup 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.V372106.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 19th September 2007 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. The range of charges the home makes is between: £380-420 per week. Extra charges are made for chiropody, newspapers, and hairdressing. Willows The DS0000029969.V372106.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 the people who use this service experience adequate quality outcomes. 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. The key inspection took place on Wednesday 17th September 2008. Prior to the visit information from the following sources was obtained and considered: The annual quality assurance assessment. This is information, which details what has happened during the past 12 months. Two surveys from one person using the service, and a health care professional. Notifications (Regulation 37) relating to incidents in the home affecting people using the service. Details of complaints and allegations raised by people connected to the service. Progress of the previous requirements and recommendations made at the last site visit. At the site visit one inspector spent five hours at the home. During this time observations of care practices took place. People using the service were spoken with and discussions with the manager regarding meeting needs, mealtimes, protecting people and the environment took place. The lunchtime meal was observed and time was spent inspecting care plans, looking at individual rooms and reviewing a selection of health and safety information. Staffing and management issues were discussed and feedback was given to the registered manager at the end of the inspection. What the service does well: People enjoy the food and drink they are offered. Having a pleasant dining area to eat in enhances this. Willows The DS0000029969.V372106.R01.S.doc Version 5.2 Page 6 People are cared for by staff that are aware of the signs of abuse, this helps to protect them from harm. There is a designated staff team who are approachable, friendly and professional which people using the service have a good rapport with. What has improved since the last inspection? What they could do better: 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 DS0000029969.V372106.R01.S.doc Version 5.2 Page 7 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.V372106.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 is not applicable) People who use this service experience good outcomes in this area. People are effectively assessed prior to admission, which helps to ensure individual needs can be met. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The three pre-admission assessments looked at confirmed that a senior person completes an assessment before an individual moves to the home. This is to check what type of care and support the person needs and whether the staff have the skills and knowledge to provide that care if the individual chooses to move there. The process also reassures the individual and their family that they will receive the right support. Willows The DS0000029969.V372106.R01.S.doc Version 5.2 Page 9 Assessments are completed if the person has a care manager or is privately funded. These detail health, personal, nursing, social and mental health needs. Surveys completed by people show that people are given enough information about the service and what it provides. This means they can make an informed choice about whether to move there or not. The manager is aware of the categories of registration, which include older people and those people with dementia. Willows The DS0000029969.V372106.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience adequate quality outcomes in this area. People have their personal care needs met, though dignity could be improved. The medication system is not robust enough to make sure people get the medication they need. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: Three care plans were looked at during this visit. These describe the care and support people need to stay in charge of their own lives as much as possible. The plans looked at contained a lot of information, so that an unfamiliar carer could look at them and would be able to work out how much support they needed. There were written assessments as to whether people were at risk of developing pressure sores, or a health problem or needing help with moving and handling. Those identified as ‘at risk’ had a care plan in place describing Willows The DS0000029969.V372106.R01.S.doc Version 5.2 Page 11 how that risk was to be managed. Most of these were reviewed and evaluated though not always on a monthly basis. Currently the home does not carry out nutritional assessments on people, the cook is aware of people’s likes and dislikes regarding food and some people are weighed. Though there is no assessment undertaken on admission to identify which people are at risk of being over weight or underweight. One plan showed that a person had lost some weight and the GP had been contacted though no specific care plan was in place and there was no evidence that this person had been re-weighed since May 2008. The manager was unsure as to whether any people in the home were under or over weight. This could put people at risk nutritionally. The home reports accidents and incidents affecting people and an audit of the number of accidents and pressure sores takes place, this helps identify areas for improvement. People spoken with confirmed that they see the GP, chiropodist and dentist when needed, and staff liaise with district nurses and staff from the community mental healthy team when needed. Some staff have completed palliative care training, which helps them understand how to care for people who are at the end of their life. Generally people looked well cared for and positive comments were received regarding the standard of care. One person said, “the staff are great, they really look after me” Another person said “staff always help me in a morning”. One comment was “staff always treat me well and they are friendly and kind”. Throughout the visit care practices were observed. Staff were observed knocking on doors prior to entering individual rooms, and staff clearly had a good rapport with people and their relatives. It was evident that some people with mobility problems on occasions were transported around the home on a commode or bath seat. This is undignified for people, and needs to be reviewed. Staff spoken with said, “We have always done this”. “On hairdressing days the commode is used because this is the only chair that will fit under the sink for washing hair” was another comment. One person confirmed that there are not enough wheelchairs to transport people around the home. Staff must ensure people’s dignity is maintained at all times. This was discussed with the manager. The medication system was inspected. Staff confirmed that they receive medication training before they are allowed to handle medication. The medication trolley has to be stored in the communal area because the medication room is too small. This is kept locked but is not secured to a wall. Medication charts were examined and whilst some had been completed effectively a range of issues were identified which potentially puts people at risk. For example stock balances of loose medication does not take place, one person prescribed Zopiclone had seven extra tablets which could not be accounted for, the number of Omeprazole stored did not tally with the amount Willows The DS0000029969.V372106.R01.S.doc Version 5.2 Page 12 administered and one person in hospital had two different tablets signed for on the medication chart over a period of fifteen days. As the medication had been taken into hospital with this person it was unclear why staff had signed for this medication to say it had been administered in the home. Staff were uncertain where Temazepam should be stored. It is currently kept in the drugs trolley, but should be kept locked in a controlled drugs cupboard. The medication policy did not contain any information regarding storage of this medication, which made it difficult for staff to get clarification. The manager confirmed that a medication audit documents is now in place and will be completed shortly. Due to the range of medication issues which are putting people at risk a visit from a Pharmacy Inspector has been arranged. Pharmacist Inspector Visit A CSCI pharmacist inspector visited on 23 September 2008 to undertake an inspection of the systems in place for the handling of people’s medicines. Following the inspection on 17 September 2008 the manager was advised to start using a medication audit tool to check that staff are following the correct procedures when handling medicines. On the day of the pharmacy inspection this had not started. The current Medication Administration Records (MARs) were looked at. There is no record of staff authorised to administer medicines. This makes it difficult to identify who was involved in administration if a problem or error was to occur. There are no dividers between the MARs. This means there is a risk that the wrong MAR chart may be read before administration takes place and medication given to the wrong person. There is inconsistency in the recording of the administration of medication. One person had medication prescribed as one daily, 5 tablets had been taken from the supply but no records of administration had been made on the MAR. Several MAR charts contained hand written entries which lacked sufficient detail to make sure the medicines could be given safely as prescribed. To make sure the record is accurate, all essential details from the label (including the quantity supplied) the date of entry, the signature of the person making the entry and a witness signature where possible should be included. One person is prescribed warfarin, a copy of the recent blood tests, the current dose and the next test date are not kept in the home. It is good practice to have these details available so that staff have access to up to date information on the person’s medical treatment. Willows The DS0000029969.V372106.R01.S.doc Version 5.2 Page 13 An audit of current stock and records showed that some medication had been signed for but not given. For example one medication had 28 capsules recorded as supplied, 5 records of administration had been made on the MAR but only 4 had been taken from the supply. This means that this person on one occasion did not receive their medication as prescribed. There was a discrepancy with the supply of medication for one person staying for a short time at the home that had not been spotted by staff. This means that staff had not performed a check on the medication when it been supplied to make sure it was correct. There is currently no controlled drugs cabinet or register to record supply and administration of these medicines. The manager was advised that under new legal requirements a cupboard and register must be obtained. A number of people self administer their medicines. This is good practice as it provides people with a level of independence. However a risk assessment had only been done for one person. This means that no check had been made to see if the other people who self administer their medications are able to do so correctly and as prescribed. A record is not kept of the medicines that are given to people when they spend time away form the home. This means that is not possible to check that the medication returned matches what the person should have taken whilst away from the home and to know that they have been taking their medicines as prescribed. Willows The DS0000029969.V372106.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 and 15 People who use this service experience adequate quality outcomes in this area. People participate in some activities and visitors are welcomed. Staff encourage autonomy and choice, and people enjoy dining in pleasant surrounding with appealing food. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home has two distinct areas for people to live. In the dementia area people have one to one discussions with staff, manicures or foot spas. Magazines, newspapers and the television are available and the atmosphere is pleasant and relaxing. Entertainers visit the home and a motivational team come and do exercises with people. The home has an activities organiser who normally spends time in the dementia area (seven people reside here). However, there is no dedicated time and staff have to fit activities around care work. People in the rest of the home stated that there are very few activities and there is little opportunity to go outside unless a visitor takes people out. Willows The DS0000029969.V372106.R01.S.doc Version 5.2 Page 15 The organiser does not have a budget to buy resources for activities, and money is raised through fundraising. The home needs to review the activities offered and the resources available. Sometimes staff have to be involved with activities in their own time and currently there is no equity in the home between older people and those with dementia. People are able to access church services and details of people’s religion are documented in people’s care plans. Key workers also complete people’s social history, whilst some files had pictures and in depth information regarding individuals, this had not been kept up to date. The home welcomes visitors at different times during the day. One visitor had come to take their relative out for lunch, however the manager was unaware of this and staff confirmed this person was already sat at the dining table having lunch. This meant the relatives had to re-arrange another day to take this person out. This should have been communicated to staff and the manager as the relative stated that she had telephoned the home the evening before to arrange this. Staff do encourage autonomy and choice. People are able to get up and go to bed when they want. One person said, “I like to be up at 6am, and this is fine with the staff”. The main dining area in the home is light and airy and pleasant to spend time in. Tables and chairs are comfortable and provide adequate support to people. Six people were sat on one table interacting well with each other whilst they waited for their food to be served. People were observed enjoy the juice they were given and a mixed grill was offered as the main course. This was very popular. People discussed the choice they have at breakfast time. One person said “I had a bacon sandwich for breakfast”, another person said,” I like cereals and toast”. The catering staff were spoken with in the kitchen. They confirmed that an environmental health officer had recently visited and had made a few recommendations. The catering staff have two domestic cookers to use. However, one was not fully working and the other was very small when catering for approximately thirty people. The catering staff knew people’s likes and dislikes and were aware of how to accommodate people who need a soft or pureed diet. Staff in the kitchen ask people if they like the food and are happy to offer an alternative to any food, which is offered. Willows The DS0000029969.V372106.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 and 18 People who use this service experience good quality outcomes in this area. People have their concerns listened to and acted upon, and people are safe and protected from harm. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home has a complaints procedure in place which people using the service are aware of. Everyone spoken to at the visit said they would be happy to speak to staff in the home if they had any concerns. People felt the manager would deal effectively with any issues raised. Meetings take place between staff and people using the service where concerns can be discussed. One complaint has recently been made regarding care practices; this was investigated with social services and the manager and found to be unsubstantiated. Staff spoken to discussed the action they would take if they witnessed any form of abuse involving people using the service, staff, or visitors to the home. Staff have undertaken abuse awareness training and the home have policies and procedures in place to explain the correct action to take. Staff were confident that the manager would know what action to take and the role social services have. People looked safe in their environment and the home has an Willows The DS0000029969.V372106.R01.S.doc Version 5.2 Page 17 open door policy where staff can discuss any concerns with the manager at anytime. This helps to minimise the risk of harm to people. Willows The DS0000029969.V372106.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 and 26 People who use this service experience adequate quality outcomes in this area. People live in a clean environment, though areas need refurbishing which would enhance the home for people. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home is welcoming, warm and smells pleasant. The area for people with dementia is well lit, bright and has contrasting colour carpets, walls, and Doors. This helps people distinguish between individual rooms, toilet areas, lounge areas and corridors. Good quality seating is provided and people looked happy in this environment. In the rest of the home where there are older people and some people with dementia areas need re-decorating. The corridors Willows The DS0000029969.V372106.R01.S.doc Version 5.2 Page 19 are narrow and dimly lit with dark brown colour doors. This makes it difficult for people to find their way around the home. Doors frames, skirting boards and some bedrooms need updating to enhance the environment. Improved security is now in place at the entrance and in the dementia area. There is a maintenance person who completes work in all of the Hexon Homes, though he is not specific to this home. People were observed wearing clean and well-ironed clothes. The laundry area is adequate and staff confirmed they have completed infection control training. Staff were observed wearing protective gloves and aprons, which helps to prevent cross-contamination. The home employ domestic staff at a range of times during the week and weekend and this helps to maintain a good standard of hygiene throughout the home. Willows The DS0000029969.V372106.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 and 30 People who use this service experience adequate quality outcomes in this area. People are cared for by staff who are competent, and in sufficient numbers. Though they are not always recruited safely, which may put people at risk. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: People are cared for by staff that generally receive enough training. The manager is supernumerary and there are senior care staff and carers who are supported by domestic and catering staff. People spoken to felt staff could meet their needs, though more one to one time would be beneficial. Staff were observed interacting well with people and knew what individual needs people had. Staff have undertaken some dementia training and the NVQ Level 2 in care is offered to all new staff. Though currently only 25 of staff have completed this. The manager discussed how people are recruited. A procedure is in place which details police checks and references. Staff files were inspected though these were disorganised and it was difficult to find the relevant information. Police checks and protection of vulnerable adults checks take place. However, not Willows The DS0000029969.V372106.R01.S.doc Version 5.2 Page 21 everyone had two written references in place. One person had a friend as a reference and no other references had been obtained. Another person and one reference in place but another had not been obtained. Staff’s training certificates were also in this file but again information was hard to locate. The manager was aware of this and is in the process of improving this system. People must be cared for by staff that are effectively recruited as this will help protect them from harm. The home have an induction process in place. This is not fully implemented and staff spoken to discussed verbal information they are given when they start working in the home, but they were unclear about which forms they need to complete in order to sign off their induction training. Willows The DS0000029969.V372106.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 and 38 People who use this service experience adequate quality outcomes in this area. The home is generally run in the best interests of the people using the service, though management systems need improving to make the home run more effectively. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The manager is registered with The Commission. She has worked with older people for many years and has a kind and caring personality. She has not completed a Managers Award yet but is hoping to do so. This will give her a greater understanding of the role of Manager. The home does not have a Willows The DS0000029969.V372106.R01.S.doc Version 5.2 Page 23 deputy but a carer has been appointed to a senior carer role and has been delegated some management responsibilities. It was evident that improvements are needed to the quality assurance system; this needs to be fully implemented to help identify how the service can improve and develop over the next twelve months. Auditing of the medication and care plan system should be a priority. This will help the manager understand if the care people receive is good and if they are getting the medication prescribed. Some auditing takes place that relates to health and safety, accidents and the prevention of pressure sores. The general manager oversees the home and supports the manager in reviewing some of the systems. There are regular staff meetings, which are documented and people have the opportunity to speak to staff at anytime. People’s finances were discussed and inspected. The home keeps wellmaintained records regarding money coming in and money going out. Details of any transaction are kept and individual envelopes are in place for each person. People spoken with confirmed that they can bring money into the home and this is safely stored. Money may be used for hairdressing, chiropody, newspapers or toiletries. Health and safety in the home was observed, a selection of records were examined and discussions with the manager took place. A fire risk assessment is used and regular fire alarm testing is evident. Staff need to be clearer about the action they would take in the event of a fire. Staff had mixed responses when asked what they would do if there was a fire upstairs. Some people said they would close all the doors and keep people in their rooms, whilst others said they would get everybody out. Some room doors were propped open why may hinder staff in the event of a fire. Staff receive a range of training which includes moving and handling, fire safety, infection control and food hygiene. This needs to be kept up to date. One member of staff explained she had been shown by colleagues how to use the hoist but has not received any formal training. This may put people at risk. The manager undertakes testing of water temperatures, this was recorded and found to be within the expected temperature range. This ensures that people do not have water, which is too hot or too cold when washing and bathing. The electricians were at the home undertaking some work to ensure the home complied with the electrical wiring recommendations. They confirmed that there were some minor issues that will be completed shortly. Willows The DS0000029969.V372106.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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 1 Willows The DS0000029969.V372106.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 OP9 Regulation 13(2) Requirement Timescale for action 23/10/08 2. OP10 12(4) (a) 3. OP12 16 (2) (m,n) 19 Sch (2) (5) 4. OP29 Medication must be given as prescribed and a record must be made at the time that it is given. This will make sure that people receive their medications correctly and the treatment of their medical condition is not affected. People must be moved around 17/10/08 the home in a dignified manner. A review of the use of commodes and bath seats for moving people from communal areas must take place. People must have access to a 17/11/08 range of activities which staff have the staff and resources to facilitate. People must be cared for by staff 17/10/08 that are effectively recruited. This helps protect people from harm. Two written references must be obtained prior to a member of staff starting work in the home. This needs to be clarified in the recruitment procedure. Willows The DS0000029969.V372106.R01.S.doc Version 5.2 Page 26 5. 6. OP38 OP9 18 13 (2) People must be moved and handled safely by staff that are suitably trained. Controlled drugs must be stored according to current guidance and safe custody regulations. The receipt, administration and disposal of controlled drugs must be recorded in a controlled drugs register designed for the purpose. This provides the extra security needed for this type of medicine and will help to prevent loss or diversion. 17/10/08 23/12/08 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 OP8 OP13 Good Practice Recommendations People should have their nutritional needs assessed. This will help staff know if they are underweight or overweight. Staff need to communicate more effectively with each other when visitors want to take their relatives out for meals. Catering staff would benefit from a new cooker; this would help make the process more efficient. The environment would be improved with better lighting in the corridor areas, and some redecoration to dark areas and areas where re-painting is needed. This would be a more pleasant environment for people to live in. The induction process needs to be fully implemented. This would help make sure that staff know how to care for people. The quality assurance system needs to be fully implanted. Care plan and medication audits are a priority. Handwritten entries on MAR charts must be accurately recorded and detailed. This makes sure that the correct information and dose is recorded so a person receives their medication as prescribed. OP15 OP19 5. 6. 7. OP30 OP33 OP9 Willows The DS0000029969.V372106.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 DS0000029969.V372106.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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