CARE HOME ADULTS 18-65
Willows (The) The Old Grove High Pitfold Hindhead Surrey GU26 6BN Lead Inspector
Damian Griffiths Unannounced Inspection 8 October 2007 11:15a
th Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 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) willows@robinia.co.uk 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.V346629.R01.S.doc Version 5.2 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) 18th April 2006 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 50, 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. Weekly care costs £1846.15 Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and took 5 hours commencing at 11:15am and ending at 4:15pm. Mr Damian Griffith’s Regulation Inspector completed the visit. The Registered Manager, Mrs Sharron Ann Foulger was present and represented the establishment. The inspector ensured that time was spent observing talking and noting interaction between care staff and service users. Service users relied on relatives and care staff to meet their care needs and to speak on their behalf. A tour of the premises was conducted and the inspector stayed for lunch. Samples of service users care need assessments, care plans and the views of service users met during the visit contributed to this inspection report and three CSCI surveys were received from service users relatives and advocates including a Social Care Practitioner. Staff files were inspected for evidence of good practice in the following areas; recruitment, training and the distribution of care staff skills as reflected in the staff rota for the day. The inspector would like to extend thanks to the service users their relatives, management and staff at The Willows for their time and hospitality. What the service does well:
The home produced good documentation and provided new service users with a comprehensive care needs assessment. The production of detailed care plans provided consistent recording of the appropriate individual service users care support that in turn promoted the confidence of relatives and advocates. The home ensured that service users were involved with appropriate activities in and around their home and local area. The homes contact with family was appreciated by relatives completing the CSCI Survey commented: Since my son has been at the Willows we do receive information of what he has been doing by the reviews where before we never received information. And The Willows are certainly keeping me up to date with (my sons) progress. I have never had this before in any of the other homes he has been in. The home had stated in its Annual Quality Assurance Assessment (AQAA) that: Photographic evidence of service users activities and holidays are included in their reviews. Relatives completing the CSCI Survey commented: By the photos I have received it certainly looks like his needs are being met.
Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 6 Staff consulted were very approachable, and aware of their cultural differences; One care staff member said; they may all come from around the world but their one thing in common was the care and well being of the service users. The inspector observed care staff carefully recording service users finances when providing cash for the service users daily activities. The home had stated in its Annual Quality Assurance Assessment (AQAA); 75 of care staff were working towards the national vocation Qualification level 2 award. The staff skill mix met the care needs of service users due to the quality of training and regular supervision available at the home and staff had been carefully vetted before being allowed to work with the service users. What has improved since the last inspection?
The home had completed the requirements made following the last key inspection: The statement of purpose contained all the information required in Schedule 1 of The Care Homes Regulations 2001. A review of the gender and ethnicity of residents and staff had been completed to ensure the needs of the residents were met appropriately and that additional staff training was supplied as required. A review of the faith and ethnicity of residents was completed to ensure that information was accurate and documented accordingly. The home had provided information relating to service users receiving signed terms and conditions of residency and had pursued this issue with the local authorities responsible. A review of the homes menu was completed to ensure a varied and nutritious diet. The home had made sure that a specified mobility aid was repaired and safe to use. 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. The CSCI was kept informed of the progress of the revision of the organisation policy and procedure regarding the protection of vulnerable adults from abuse. The induction programme for non-overseas members of staff had been implemented.
Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 7 CSCI was informed of the training provision regarding communication for all members of staff. CSCI was informed of the dates planned for the re-decoration and repairs of the home. CSCI had been made aware of the proposed date for the homes quality assurance audit. A copy of the written confirmation of agreement with the water board was forwarded to the CSCI. The socket for the chest freezer had been re-sited and all open foodstuffs were stored in the refrigerator contained the date marked on opening. 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) DS0000013887.V346629.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 were inspected and the quality in this outcome area was good. The Home had produced good documentation and provided new residents with a comprehensive care needs assessment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home had reviewed its statement and purpose and copies could be made available to resident’s relatives and advocates. The home had stated in its Annual Quality Assurance Assessment (AQAA) that it had: Distributed to families and social workers our Statement of Purpose and updated complaints policy. The requirement made at the last inspection had been met. Service user care needs were complex and varied and it was accepted that they would not find the service users guide of interest and relied on relatives/advocates to promote their best interests. A new resident had recently joined the home and was receiving their six-week placement review. The inspector was able to talk briefly to the service user during the inspection. The services user was able to speak to the inspector and indicated that the home was good and that he was looking forward to having his own room, the manager confirmed later that all the service users have their own rooms. The service user had received a comprehensive care needs assessment that included:
Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 10 Personal care needs, weekly activities, health care needs, mealtime preferences and care at night routine. The manager informed the inspector that the family had been introduced to the home by a social care practitioner and as yet had not received full information relating to the home and confirmed that they will receive full details of the home including copies of the statement of purpose. The social care practitioners conducting the review informed the inspector that the home was good and another confirmed in the CSCI survey that the home ‘usually’ gathered accurate information and the right service was planned. The manager was aware on the difficulties obtaining a record of service users contractual agreement signed by the service user or their representative/advocate and had written the respective local authorities on two occasions requesting this service but without success. CSCI recognised that the home has taken reasonable measures to achieve this task therefore meeting the requirement but recommends that the registered manager seek advocacy support to realise this task. Please refer to the recommendations section of this report. Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, and 9 were inspected and the quality in this outcome area was good. Service users benefited from detailed care plans that promoted and enabled staff to meet the assessed needs of the service user and promoted the confidence of advocates and relatives with the standard of care being delivered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three service user care plan folders were inspected and they contained detailed information that benefited staff and residents. Care had been taken to summarise all the main areas of likes/dislikes, disability and care need into an easy-to-read-folder for staff to read. The home operated a ‘Key-worker system that furthered the procedure for focused individual work and understanding of service user care need. The new service user and staff were in the process of developing his ‘Personal Lifestyle Plan’. All care plans inspected contained information relating to service users personal preferences, including what food was liked and a activities preferred. Care plans had been reviewed and the home used photographs to illustrate service users activities that were sent to relatives.
Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 12 Staff consulted about the care needs of the service users were informative, open and knowledgeable about the service users needs and informed the inspector of their individual key worker responsibilities. Risk assessments were in place and related to the information shared with CSCI when recording significant incidents involving the service user such as accidents as required under (Care Homes) regulation 37. Relatives completing the CSCI Survey commented: Since my son has been at the Willows we do receive information of what he has been doing by the reviews where before we never received information. And both relatives confirmed that the home meets the needs of their sons. By the photos I have received it certainly looks like his needs are being met. Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15, 16 and 17 were inspected and the quality in this outcome area was good. The home ensured that service users were involved with appropriate activities in and around their home and local area. Family contact was generally acceptable and service users received active support to ensure nutritious food was available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service user care needs were complex and varied and dependent of the staff to support them. Service users were, in the main, participating in activities outside of the home: day centres, and walks in and around the local area including shops and restaurants. The home had stated in its Annual Quality Assurance Assessment (AQAA) that: Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 14 Photographic evidence of service users activities and holidays are included in their reviews, as mentioned in the previous section of this report. Holiday’s photographs of service users were observed throughout the home. One service at home was playing his favourite music. The service users were all British citizens but with different ethnic backgrounds receiving care and support from a mainly diverse overseas staff group. The manager and deputy manager were fully aware of the potential for cultural misunderstandings and the training courses at the home were in place to address this. Staff consulted were very approachable, and aware of their cultural differences; One care staff member said; they may all come from around the world but their one thing in common was the care and well being of the service users. Two requirements were made at the last inspection relating to equality and diversity issues. This requirement had been fully met. A relative completing the CSCI survey commented: They (staff) do support me to take my son to church. Family members were divided in their response to CSCI survey question regarding the home keeping them informed of events: One relative commented on the lack of information available: I ask repeatedly for phone calls to update on my sons activities…they are supposed to call me every 2 weeks but they do not. And: The Willows are certainly keeping me up to date with (my sons) progress. I have never had this before in any of the other homes he has been in. The home had stated in its Annual Quality Assurance Assessment (AQAA) that they were: broadening the use of photographic communication to promote greater aspects of choice, such as meals of choice. The manager and staff were enthusiastic about this approach to communication and the potential for better understanding based on photographs identifiable to the service user, however, one service users response to a photograph of his favourite meal was to dismiss it due to the photograph being flat and one-dimensional. Service users received regular input from the local health care dietician. A requirement was made at the last inspection that nutritional value of service users meals be reviewed. This requirement had been met. Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18,19 and 20 were inspected and the quality in this outcome area is good. Service users health care needs were well documented and catered for however staff administration of medication was in need of improvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has ensured that each service user received the appropriate health care support, as seen in the comprehensive care assessment. In addition to this each service user had a comprehensive health care folder detailing current health care input and service user preferences. Behaviour plans ensured that service users emotional needs were served, each care plan section featured information relating to service users particular behavioural ‘trigger point’ to challenging behaviour or distress therefore staff had the means to be aware and to ensure that service users received treatment the way they preferred. The repair of service users equipment was an issues at the last inspection whereby a requirement to improve was made. At the time of the inspection a wheelchair repairman was on site. Service users required the assistance of staff for all the health care needs including their reliance on receiving regular medication as prescribed by their General Practitioner. The inspector sampled Medicine Administration Record
Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 16 (MAR), packaged medication storage including controlled drugs and disposal practices at the home. It was discovered that the MAR’s had not been fully completed by staff for the previous shift. All other areas of inspection were in order. A requirement was made at the last inspection to ensure that all staff had the appropriate medication administration training and this had been implemented by the home. The inspector was informed that the home’s the current practice was for two care staff to be involved with the distribution of medication in order for one to witness the other’s administration at all times, therefore, the home must investigate and inform CSCI of how this failure had occurred. The service users tablets were absent from the blister pack indicating medication had been administered. Please see the requirement section of this report. Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were inspected and the quality in this outcome area was adequate. There were no complaints outstanding. Service users were able to express themselves freely and were support by staff that were aware of safeguarding procedures however some areas of care could be improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users were seen to direct staff and service users also took the inspector for a walk around the premises. Safeguarding vulnerable adults procedures were in place at the home and the manager and her deputy had received training. Staff had access to the office and the safeguarding procedures, received training and information posters were situated in the manager’s office. At the time of the inspection there was no safeguarding or complaint issues to investigate or report and there was evidence in place to show that the complaints system was being used satisfactorily. A requirement was made at the last inspection for the home to show evidence of revised policy in place safeguarding service users and recompense of payment following a financial audit of service users accounts in 2005. This requirement had been met. On inspection of the homes policy it was shown to be out of date and did not explain bank-charging measures. A requirement was made for the home to provide CSCI with an up-to-date policy to explain the charging system.
Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 18 The inspector was required to instruct staff to dress a service user without socks on who had been left to get cold while the staff member attended to another task. Please see the requirements section of this report. Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. The home environment provided service users with a comfortable and homely environment however more care needed to be taken when cleaning service users bedrooms. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was reasonably clean and tidy and provided door exit alarm systems to ensure that staff supported service users. The service users had full access to all areas in the home that were safe including the outside of the building and one service user was able to show the inspectors around the premises and his bedroom. Staff had ensured that each service users bedroom was a personalised and reflected the service users personality, likes and choices. Two of the residents’ bedroom however could have been cleaned better and the smell of urine and other unpleasant odours was noticeable. The manager was made aware. A service user relaxing in the lounge had been receiving a foot massage. The member of staff was observed cooking the evening meal and appeared to of
Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 20 forgotten to replace his socks. The service users feet were cold due to the temperature of the lounge. More care needs to be taken to ensure that room temperatures are consistent with the activities of the home and activities completed properly before staff begin another task. The home was situated in a leafy environment surrounded by trees and safe lanes to stroll, service users were witnessed to be taking full advantage with the support of staff. A social care practitioner completing the CSCI Survey commenting about her client at the home: He appears more relaxed and happy since living at the Willows although it is a large service the environment meets his needs. Please see the requirement section of this report. Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 and 36 were inspected and the quality in this outcome area was good. The staff skill mix met the care needs of service users due to the quality of training and regular supervision available at the home and staff had been carefully vetted before being allowed to work with the service users however there were some staff shortages. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Relatives and social care practitioners completing the CSCI Survey commented: Managers and staff ‘usually’ had the right skills and experience to support service users at the home. The home had stated in its Annual Quality Assurance Assessment (AQAA); 75 of care staff were working towards the national vocation Qualification level 2 award. The home was required to show that robust recruitment procedures were in place by detailing the person’s previous employment status, providing complete criminal record checks for all staff, proof of identity, ensuring that two references and full employment histories were available in the staff file for inspection.
Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 22 Five care staff files were inspected and showed that all files contained the requisite two references and employment history. Criminal record checks and proof of identity were all in place. The registered manager confirmed that there were four staff vacancies at the time of the inspection and recruitment for staff overseas was being considered. The organisations induction plan for staff from overseas includes a session on attitudes toward learning disability, relationships with professionals, definitions of learning disabilities and epilepsy. The staff spoke of having regular training, therefore samples of five staff files were inspected to see whether ‘skill mix’ and ‘training’ reflected the care needs of the service users. Files showed that all staff had received a good basic training: basic health and safety including food hygiene and infection control, safeguarding adults and disability awareness. Staff rota’s were checked and training matched against the staff on duty showed that staff has received; awareness of autism and epilepsy training that was relative to the needs of the service users. Other training included: Makaton, communication skills, first aid, medication administration and specific training relating to the epilepsy medication. Care staff also received regular supervision where discussions relating to training, appraisal and issues relating to the home and service users. Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39,40, 41 and 42 were inspected and the quality in this outcome area was adequate. The manager was well qualified, experienced and was aware of strengths and weaknesses of the service and had sought the views of relatives and people involved with the home. The home needed to ensure that all the policies and procedures in use were up to date and health and safety measures were regularly reviewed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Willows is well situated within secure grounds that were shared with the head office and other homes run by the Robinia organisation. The registered manager had worked within the organisation for a number of years and therefore knew about the organisational needs of the service and service users. She was aware of the complexities of managing a mix of overseas staff and the potential for misunderstandings and limitations to staff team cohesion and will be exploring this at the next staff team development
Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 24 day. Permanency of staff also appeared to be an area of concern for relatives completing the CSCI Survey commented; At the moment the staff at the bungalow seem stable i.e. not a lot of new faces for a while there seemed to be new faces quite regularly which means that staff do not have time to build up on knowledge about the service users which means lack of consistency. Relatives went on to comment in the section; ‘How could the home improve’; sometimes I ask staff for something not to be done…and they (staff) continue to do it. And; Try and keep staff that service users get used to, we noticed there was a lot of agency staff used. The home had stated in its Annual Quality Assurance Assessment (AQAA) and in answer to ‘Barriers to Improvement‘: Recruitment of staff from the locality, and understands that home will be continuing to recruit from abroad. The manager supported an open door policy however due to constant service user interest in the office it was necessary to keep the office door locked. It is recommended that the home consider fitting a window in the office door in order to uphold the open door policy in a practical way and promote communication. Service users accounts were inspected and good practice was observed. Old bank statements showed that some service users had been accrued bank charges. A policy explaining Robinia’s policy relating to service users accounts was not available. There was no evidence to suggest that service users were now paying bank charges however clarification of Robinia’s service user finance policy was required. The Inspector was informed that the policy relating to service users finances was out of date. An organisation audit was completed 23/06/06 and quality assurance questionnaires were sent to parents, social workers and service users and internal audits were completed. It is recommended that the results of these quality audits be distributed to relatives/advocates of the service users and CSCI. Relatives completing the section of the CSCI survey entitled; ‘What the home did well’ commented; keeping me informed about (my sons) well being. And another stated: The relationship that I have with care home staff is good. They listen to me, they involve me, and they consult me. They support my son to stay in contact with other members of his family, i.e., grandparents, which I think is important. Health and safety training was received by staff and a comprehensive induction program was in place. Staff also benefited from detailed records of service user risk assessments and safety procedures. A tour of the premises was conducted and inspection of the kitchen area and refrigerated foodstuffs Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 25 confirmed that there were no further concerns relating to the previous inspection requirements. Staff attention to room temperatures when service users were engaged in inhouse activities such as foot-massage required further action. The manager had ensured that requirements from the last inspection had been met and acknowledged areas of work requiring improvement with health and safety mentioned in this report: medication administration, staff vacancies, policy update, decoration and cleaning. Please see the requirements section of this report. Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 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 3 26 3 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 2 2 3 X Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 27 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 YA20 Regulation 13(2) Requirement Timescale for action 08/11/07 2. YA23 3. YA24 4. YA24 5. YA41 The registered manager must review the recording, handling, and safekeeping, safe administration of medicines received into the care home. 12(1)(b) The registered manager must ensure that staff properly assess the holistic needs and benefit to service users when engaged in activities such as foot massage. 16 (2)(k) The registered manager must ensure that service users room are hygienic and are without bad odours due to regular cleaning and odour control. 23(2)(p) The registered manager must ensure that activities requiring service users to be exposed to room temperatures when receiving such things as foot massage, the ‘room temperatures’ must be altered to reflect the health care needs of the service user as appropriate. 17(3)(a)(b) The registered manager must ensure that full documentation be made available to the CSCI relating to the management of
DS0000013887.V346629.R01.S.doc 08/11/07 08/11/07 08/11/07 23/11/07 Willows (The) Version 5.2 Page 28 service users bank accounts and charges. 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. Refer to Standard YA5 Good Practice Recommendations It is recommended that the home continues to pursue advocates to assist the local authorities and service users who currently are without signed and terms and conditions. It is recommended that the home consider uncovering the window in the office door in order to uphold the open door policy in a practical way to promote communication. It is recommended that the results of quality audits be distributed to relatives, advocates, social and healthcare practitioners and CSCI. 2. YA37 3. YA39 Willows (The) DS0000013887.V346629.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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) DS0000013887.V346629.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
