Inspection on 18/04/06 for Willows (The)

This inspection was carried out on 18th April 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Willows (The) 10/09/08

Willows (The) 08/10/07

Willows (The) 21/10/05

Willows (The) 29/06/05

Willows (The) 20/10/04

Willows (The) 30/06/04

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

CARE HOME ADULTS 18-65 Willows (The) The Old Grove High Pitfold Hindhead Surrey GU26 6BN Lead Inspector Susan McBriarty Unannounced Inspection 11th April 2006 10:10 Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 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) DS0000013887.V289138.R02.S.doc Version 5.1 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) DS0000013887.V289138.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Willows (The) Address The Old Grove High Pitfold Hindhead Surrey GU26 6BN 01428 609851 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) Robinia Care South Limited Mrs Sharron Ann Foulger Care Home 10 Category(ies) of Learning disability (10), Sensory impairment (2) registration, with number of places Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 18-50 YEARS Of the ten (10) service users in category LD (Learning Disabilities), two (2) may also fall within the category SI (Sensory Impairment) 21st October 2005 Date of last inspection Brief Description of the Service: Robinia Care Ltd provides a range of residential and day services for people with disabilities on the Old Grove Site at High Pitfold Hindhead. The Willows is a detached bungalow that offers long term residential care for up to 10 adults aged between 19 and 35, with learning disabilities who require a high level of support. The care home has 10 single rooms, three bathrooms and a shower room. The home can be viewed as having two units each providing support for five service users whose rooms are situated in each unit. Each unit has large lounge/dining rooms, although kitchen and laundry facilities are shared. Although designed as two units service users were able to access all areas of the home. Service users have ready access to the immediate grounds, which consists primarily of a hard surface area. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection for this home using the Inspecting for Better Lives process. The inspection was a ‘key’ inspection ensuring that all the core standards of The National Minimum Standards were considered. A variety of methods of collecting the information have been used including the action plan provided by the home following the last inspection, documents seen during the visit; for example care plans, risk assessments and menu’s etc. It was not possible to use the pre-inspection report, as this was not returned to the Commission for Social Care within the required timescale. The visit began at 8.30am, was unannounced and took eight (8) hours. During the visit members of staff were spoken with, residents were observed interacting with staff and discussion took place with the manager, area manager and regional general manager. What the service does well: What has improved since the last inspection? The organisation’s homes in Surrey have been subject to a review by the CSCI, a number of the matters have now been resolved or are nearing completion. These matters are now noted here more fully. 1. Resident’s finances from February 2002 to January 2005 had been of concern. The organisation has agreed with the CSCI and under Surrey County Council multi-agency procedures that recompense will be paid to all the service users in residence during that time. Payments will be dealt with on an individual basis and may take into account pro-rata amounts. 2. Payments for holidays, meals out of the home and any other additional staff costs have ensured that; (a) Holidays are either part funded by Robinia Care South or that each prospective resident will have £500 toward the cost of an annual holiday included in his or her fee. See Standard 14.4 of the National Minimum Standards for Young Adults (18-65). Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 6 (b) (c) Additional staffing costs will not be taken from resident’s own monies. Residents will not fund meals out for staff nor will they pay the full cost of the meal. This as the cost of meals is inclusive in the fee; the difference will be funded directly by the resident. 3. Residents through their mobility benefits were paying for transport provision. This method had not clearly been agreed with local authorities or families and or residents. This matter has been resolved and individual agreements made with appropriate persons completed to ensure that any payment made is agreed and recorded clearly. 4. The organisation has introduced a new policy and procedure for dealing with resident finances in order to ensure that members of staff follow consistent guidance. Members of staff have received training on this matter, as have the managers of the homes. 5. The organisation has provided each home with a clear chart informing staff of what to do and what not to do in the event of an allegation of adult abuse. The organisation has agreed to revise their policies and procedures in relation to the protection of vulnerable adults to ensure they are clear, easy to follow and are in line with local guidelines. This matter has not been confirmed as being finalised as yet. 6. Further training for members of staff was also agreed as part of the service review. The organisation has employed a specialist service to train Robinia Care South members of staff to communicate and engage with their residents more effectively. In particular engaging with individuals who have non-verbal communication needs. At the time of this visit the staff team of The Willows reported that only the manager had received this training and had provided the team with information from the course. What they could do better: The majority of people resident in The Willows are non-verbal and the remaining staff team would benefit from full training in ‘interactive’ communication in order to enhance their skills. For the Robinia Care Group to complete the revision of their protection of vulnerable adults policy and procedure as agreed as part of the service review and to inform the CSCI when completed as required. During this visit it was noted that the brakes for a mobility aid were not working, regular and thorough reviews of the equipment should include mobility aids to ensure they are in good working order at all times. The recording of medication into the home with regard to the controlled medication record had an error. An immediate requirement was made to ensure that the matter was investigated by the home and the outcome sent to the CSCI. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 7 The organisation provide employment to a diverse number of people and where the gender and or ethnic mix does not match those of the residents additional training may be useful. This to ensure that awareness of difference enables the staff team to meet the needs of a resident as closely as possible and clearly highlight any areas where there might be a shortfall. 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. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 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) DS0000013887.V289138.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,5 Further work is required to ensure that the statement of purpose and terms and conditions are accurate, in place and agreed. EVIDENCE: The home’s statement of purpose had received some updating and hand written changes were evident. However there were still areas that required review and updating for example there was still no mention of the home providing for people who challenge as had been discussed during the last inspection and noted in the inspection report. A further requirement is made to ensure that the statement of purpose contains all the information required. The resident files sampled were of those who had been living at the home for some time and did not contain pre-admission assessments. The pre-admission assessments had not been completed for those where an internal transfer had been agreed or if they were new to the service. This matter has previously been discussed with the organisation and all new prospective residents including those being transferred will be assessed prior to admission to the home. Robinia Care has previously been required to provide accurate and up to date terms and conditions for each of their residents. These were not in place at the time of the visit on the 18th April 2006. The area manager informed the CSCI that these documents will be sent to the appropriate local authorities and family members for agreement and where possible signature. A requirement is made that the home keep the CSCI informed of the progress of this work. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Care plans and risk assessments are in place and indicate the high level of care and support required by the residents. However further work is required to ensure that faith and cultural needs and preferences are up to date and accurate. EVIDENCE: Detailed care plans and risk assessments were in place on each of the resident files sampled. A number are at the point where they require review although they are not significantly out of date. The records and documents indicate the faith and ethnicity of particular residents, in sampling previous documents it was found that the information regarding attendance at church was not correct and the faith of another person could not be fully confirmed. A requirement is made that the home review the information held and seek ways to ensure it is up to date and correct. The residents of the home have significant disabilities and this impacts on their ability to make decisions including financial decisions. The home and or other external bodies manage the resident’s finances. The residents are reliant on others making decisions on their behalf. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Leisure activities including formal arrangements are in place. Members of staff support residents in maintaining contact with family members. Further work is required to ensure that meals are varied and meet the assessed needs of the residents. EVIDENCE: The residents of the home have significant learning disabilities and in a number of instances some physical disabilities. The residents are reliant on the support of members of staff and are not able to access employment or take part in voting in elections. The manager was not aware of any particular need regarding faith, culture or ethnicity that was not being met. However some of the details regarding the faith needs of two residents required clarity. A requirement is made (see Individual needs and choices) to ensure information is up to date and accurate in order to enable the home to meet any further identified needs. The majority of residents attend either the day centre on site or local authority day centres as part of their leisure and learning activities. Access to the community as a regular feature of their support can be problematic due to some of the behaviours that can challenge members of staff and others. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 12 The staff group at the time of the visit did not fully reflect the gender and ethnicity of the residents. Eight (8) of the staff are from the Philippines of whom four (4) are male; two (2) are from Slovakia of whom one (1) is male and five (5) are white British and are all female. The nine (9) residents are all male of who eight (8) are white British. A recommendation is made that the home review how they ensure they meet the gender and ethnicity needs of the residents and consider what additional training might be needed. The organisation has an equal opportunities mission statement and the CSCI were informed that diversity training is part of a two hour training session on standards and values. The organisation has now resolved the matter of the cost of holidays as part of the service review by the Commission for Social Care Inspection (CSCI). The updated terms and conditions state that £500 of the fee will go toward the cost of a holiday. Current residents, unless there is an alternative agreement, will receive the same amount of money from the organisation toward their holiday. Documents kept by the home record all contact with family and friends and assessment information notes what family contact might be expected and any sensitive information that is important for members of staff to be aware of. Only one of the residents is able to use the key to their bedroom door although this remains in the lock at all times, as there was a possibility of the key being misplaced. The remaining residents are not able to use a key due to the extent of their disabilities. One resident was able to assist with some of the tasks involved in carrying out their laundering needs and was observed enjoying the process. The residents do not have unrestricted access to the wider grounds for safety reasons, however they are able to access the patio area without support from members of staff. Transport is available to the home and the organisation has reviewed the funding arrangements for the provision of transport. The funding arrangements for each resident have been agreed with purchasers. This change is an outcome from the service review carried out by the CSCI and a protection of vulnerable adults investigation. Observations during the visit noted a good relationship between members of staff and residents particularly at meal times. Preparation for lunch and lunch were observed. Lunch was pre-prepared frozen pies and vegetables. The food was either cut or mashed to enable residents to eat as safely as possible and with assistance where necessary. The manager discussed the menu plan and showed the inspector a single page document noting what meals are available over a seven day period. Three Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 13 choices were set against each day for the main meal the choices offered were not which might be preferred on a given day but which was to be provided on that day. All the food provided is frozen and or pre-prepared. The freezer held a quantity of frozen carrot and swede. A requirement is made that the home review the menu to ensure a greater variety of foods and a recommendation made to consider ways to introduce fresh foodstuffs. Observations made during the preparing of lunch were positive. On two separate occasions two residents were seen either taking part in the process of organising food or watching members of staff who were taking the time to explain what was happening at each step of the preparation. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Personal support and health care needs are documented in detail. Further work is required to review provision of equipment to further safeguard health needs. The administration of medication requires some further work to ensure that all the points in Standard 20 of The National Minimum Standards are met. EVIDENCE: The care plans sampled were detailed and included information regarding contact with health professionals. For example each resident has a full health check annually, the same General Practitioner holds a regular surgery in the on site day centre. The manager informed the CSCI that opticians’ appointments are bi-annual apart from one person who attends an ophthalmologist regularly. The manager also reported that the dentist had seen the residents three months ago. Specialist health provision was stated by the manager as being on an as necessary basis. One of the residents uses a mobility aid and the inspector observed an attempt to stand using the aid and was concerned to discover that the brakes were not working. This resulted in a fall (no injuries were sustained). An immediate requirement was made to ensure that the brakes were made good and working correctly and safely. A further requirement is made to review the mobility needs of the person and to consider additional equipment such as kneepads. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 15 The home provides for people with significant needs including Epilepsy, it is required that the home investigate issues regarding medical consent to ensure that all members of staff are aware of how decisions are made and by whom. The administration, storage and recording of medications were sampled during the visit. All the residents of the home require full support regarding the administration of medications including homely remedies such as paracetamol. The medication administration records sampled had no gaps where administration was confirmed. On sampling the controlled medications record and storage an error was found. An immediate requirement was made to ensure that the matter was investigated thoroughly by the manager. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Work has been completed to ensure that members of staff have an accessible format to assist in responding to allegations of abuse. The organisations review of their policy and procedure regarding allegations of adult abuse have not yet been completed. The complaint procedure met standard 22 of The National Minimum Standards. EVIDENCE: As part of the service review carried out by the CSCI the organisation had provided an easy to read poster for members of staff to read to ensure they knew what they should or should not do in the event of an allegation of abuse. A copy of the poster had been placed in the staff sleep-in room of the home. A copy of do and don’ts in the event of an allegation as supplied in the local authorities guidelines for the protection of vulnerable adults had been laminated and was on the wall in the office. The area manager stated that the concerns/complaints/allegations flow chart provided by the organisation was in the process of being further reviewed to ensure clarity. It could not be confirmed during this visit that the organisation had completed the review of their policies and procedures in relation to the protection of vulnerable adults. A requirement is made to inform the CSCI of progress to date regarding the revision. The residents of the home are reliant on others to ensure their safety and wellbeing and to make any complaint on their behalf due to the extent of their disability. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 17 As part of the review of services carried out by the CSCI the organisation introduced a new detailed policy and procedure to manage the finances of their residents. Recompense for particular expenditure between February 2002 and January 2005 will be agreed for each resident in adult homes in Surrey. The manager was not aware of any details regarding recompense. The Regional General Manager informed the CSCI during the visit that the matter was in hand. A requirement is made to ensure that the organisation keep the CSCI informed of progress and the detail of the outcome of recompense payments to residents. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 The home’s premises are accessible and generally in good order some work is required regarding redecoration. The home was clean and hygienic at the time of the visit. EVIDENCE: A tour of the home took place. The single bedrooms had been individualised and were clean. One lounge had small areas that required being made good where screws had previously been placed and where the ceiling required a small repair. The second lounge was in need of redecoration and the manager informed the CSCI that redecoration was due but did not have a start date at the time of the visit. Sluicing facilities are provided and the door is kept locked. As stated earlier in this report one resident was assisting with his laundry and a member of staff was present throughout. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Recruitment procedures and training information were available in the home. EVIDENCE: The action plan from the last inspection confirmed that named members of staff were to commence their National Vocational Training in early 2006. A copy of the organisations induction plan was received by the CSCI on the 3rd April 2005 noting the overseas staff induction programme. A requirement is made to confirm the content of the induction programme followed by nonoverseas members of staff. The overseas induction programme includes a session on attitudes toward learning disability, relationships with professionals, definitions of learning disabilities and epilepsy. Intensive interaction a training programme to assist in understanding communication with residents was reported by members of staff as having been attended by the manager who fed back the details to the staff team. A requirement is made that confirmation of staff training in intensive interaction is provided to the CSCI as part of the agreement made following the service review by the CSCI. One member of staff’s personnel file was sampled, a new starter. The file contained all the information required. The application form requests a five year employment history from prospective applicants. A requirement is made Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 20 to ensure that application forms request a full employment history including the reason for any gaps in service. Satisfactory Criminal Record Bureau (CRB) checks are sought for each member of staff and a central record is held. The home had held back a number of the original CRB documents for the CSCI to inspect. The manager was advised to follow CRB guidance regarding the timescale for disposal. Details of the training completed by members of staff were held on a central record within the home. The record shows each member of staff, the training required and the date completed. Staff training regarding diversity, as noted previously in this report, takes place in a two hour session on standards and values as part of the induction. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The manager was appropriately qualified for the role. Further information is required to confirm a date for the introduction of a quality assurance audit. Health and safety regarding the premises is well considered. EVIDENCE: The manager has the appropriate qualifications for the role including a degree in an associated field and has worked in the same environment for over ten (10) years. A pre-inspection report was sent to the home by the CSCI for completion by the 19th April 2006. The document had not been received by the 21st April 2006. The action plan received by the CSCI following the last inspection report notes that an action plan for the introduction of a quality assurance process had been completed by the 2nd December 2005. A requirement is made to confirm a start date for the quality assurance process. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 22 Fire safety checks were completed on 24/11/05. Fire equipment checks were completed on 31/10/05. Electrical items check completed on 19/12/05. Portable electrical tests were completed in January 2006. Confirmation that the organisation had reached agreement with the Water Board had been requested in 2005 as part of another inspection report, this had not been received by the CSCI. During this visit the General Manager confirmed that a copy of the document would be forwarded to the CSCI. A requirement is made that a copy of the confirmation from the water board be forwarded to the CSCI. Refrigerator and freezer temperature records were checked and recorded daily by members of staff. The vacuum on the door of the upright freezer was easily opened and a recommendation is made that staff remain mindful of this and ensure temperature records remain within the limits expected. Little room is available to allow the lid of the chest freezer due to the siting of the socket, if opened too far the lid hits the plug and may eventually create a hazard. A requirement is made to review the siting of the socket or the freezer. Some items of food were stored in the fridge and the date of opening had not been marked on the packaging. A requirement is made to ensure that all opened food stored in the fridge is date marked on the day of opening to reduce the risk of food poisoning. No substances hazardous to health were observed as being inappropriately stored on the day of the visit. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 23 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 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 2 X X 2 X Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 24 YES 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. 1 Standard YA1 Regulation 4 Requirement The registered person must ensure that the statement of purpose contains all the information required in Schedule 1 of The Care Homes Regulations 2001. Previous timescale of 30/11/05 not met. The registered person must inform and keep informed the CSCI regarding the progress of providing a contract of terms and conditions for residents. Timescale not met The registered person must review the gender and ethnicity of residents and staff to ensure the needs of the residents are met appropriately and that additional staff training is supplied as required. The registered person must review the faith and ethnicity of residents to ensure that information is accurate and documented accordingly. The registered person must review the current menu to ensure a varied and nutritious DS0000013887.V289138.R02.S.doc Timescale for action 26/05/06 2 YA5 5 18/04/06 3 YA6 15,12(4) (b)18(c) 26/05/06 4 YA6 15, 12(4)(b) 26/05/06 5 YA17 12(3), 16 (2)(i) 26/05/06 Willows (The) Version 5.1 Page 25 diet. 6 YA20 13(2) The registered person must review the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. 13(4) The registered person must ensure that the specified mobility aid is repaired and safe to use. 13(4) The registered person must review the needs of the person requiring the mobility aid and consider the use of such items as kneepads to reduce the risk of injury. 13(4) The registered person must explore issues relating to medical consent and ensure that all staff members are aware of the outcome. 13(6) The registered person must inform the CSCI of the progress of revision of the organisation policy and procedure regarding the protection of vulnerable adults from abuse. 13(6) The registered person must inform the CSCI of the progress of recompense payments to those service users resident during the period noted in this report and as previously agreed. 18(1)(a) The registered person must confirm the induction programme for non-overseas members of staff. 18(1)(c)(i) The registered person must inform the CSCI of the training provision regarding communication for all members of staff. 2 The registered person must inform the CSCI of the dates planned for the re-decoration and repairs noted within this report. DS0000013887.V289138.R02.S.doc 20/04/06 7 YA18 20/04/06 8 YA18 22/05/06 9 YA19 22/05/06 10 YA23 14/05/06 11 YA23 14/05/06 12 YA35 14/05/06 13 YA35 14/05/06 14 YA24 14/05/06 Willows (The) Version 5.1 Page 26 15 YA39 24 16 YA42 13(3) 17 YA42 13(4) 18 YA42 13(4) The registered person must provide the CSCI with the proposed date for the homes quality assurance audit. The registered person must ensure that a copy of the written confirmation of agreement with the water board is forwarded to the CSCI. The registered must ensure that the siting of the socket for the chest freezer be reviewed or resite the freezer if required. The registered person must ensure that any and all open foodstuffs stored in the refrigerator are date marked on opening. 14/05/06 14/05/06 22/05/06 27/04/06 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 Refer to Standard YA17 YA42 Good Practice Recommendations It is strongly recommended that the home review the provision of frozen foods and consider introducing fresh produce. It is recommended that all members of staff remain mindful of the freezer door seal and ensure that storage temperatures do not fall below recommended levels. Willows (The) DS0000013887.V289138.R02.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 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) DS0000013887.V289138.R02.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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