Care Home: Burley Willows Home For Older People

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What the care home does well What has improved since the last inspection? The home continues to provide a high level of care to people living at the home. Information in the AQAA states: "Several improvements to the environment, new flooring to the main area and several bedrooms. More staff trained to NVQ 2 More resident/relative meetings Lifestyle plans have been improved." There has been a lot of work to improve the environment with new furniture and fittings in bedrooms. More regular meetings are held with people to involve them in the running of the home and the planning of activities. Staff are trained to a high level so that they know how to look after people properly. What the care home could do better: The managers continue to strive to improve the service and facilities to people living at the home. They are clear about where improvements can be made. Information provided in the AQAA states: "More in house training. Fire refresher training already done, equality and diversity to be arranged, cultural awareness booked. Continue to improve the activities for residents and try to raise more funds for trips etc To continually improve the environment" Thery are also clear that they need to continue to develop care records to make sure that staff have enough information so that they can look after people in the way that they want. CARE HOMES FOR OLDER PEOPLE Burley Willows Home For Older People Willow Garth Leeds LS4 2HL Lead Inspector Catherine Paling Unannounced Inspection 09:40 3 November 2008 rd 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 Burley Willows Home For Older People DS0000033139.V372908.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. Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burley Willows Home For Older People Address Willow Garth Leeds LS4 2HL 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) 0113 2456579 0113 2456579 Leeds City Council Department of Social Services Mrs Kathryn Louise Yeoman Mrs Collette Noelle Shekarchi-Khanghahi Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2007 Brief Description of the Service: Burley Willows is a local authority home providing personal care primarily for older people of both sexes. There are 30 permanent places including three places for short term care and two places for intermediate care. The home is single storey and there is level access throughout the building. Accommodation is in single rooms, all of which have their own washbasin. None of the rooms have en-suite facilities but the three bathrooms and two shower rooms are of a high standard and allow for full assistance. There are plenty of toilets situated throughout the building. There are six lounges, one of which is a designated smoking area, and all lounges have television and hi-fi units. There is level access to the enclosed gardens. The home is situated about two miles from Leeds City Centre and is close to many local amenities including shops, library, doctors and dentist. Information about the service is available in a Statement of Purpose and Service User Guide. These documents are reviewed regularly to make sure that the information is up to date. They are accessible throughout the building together with copies of the most recent inspection report. The fees range from £102.90 to £497.30 per week. There are additional charges for chiropody, hairdressing and newspapers. This information was provided by the service at the November 2008 visit and is displayed in the home. Burley Willows Home For Older People DS0000033139.V372908.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 3 star. This means the people who use this service experience excellent quality outcomes. This was an unannounced visit by one inspector who was at the home from 09.40 until 15.10 on 3rd November 2008. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the inspection visit. A number of documents were looked at during the visit and all areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people at the home as well as with the manager and the staff. An Annual Quality Assurance Assessment (AQAA) had been completed by the home before the visit to provide additional information. This is a selfassessment of the service provided. Survey forms were sent out to the home before the inspection providing the opportunity for people at the home, visitors and healthcare professionals who visit to comment, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. No surveys had been returned by the time of this visit. However, the home’s own survey material has been used as well as comments received from people on the day of the visit. What the service does well: Information provided in the AQAA states: “We feel that we provide a safe, warm and friendly environment where service users are treated as individuals and encouraged to speak their mind about the service we provide. We have an open door policy as much as possible and have good relationships with other professionals such as district nurses, chiropodist, ICT staff, Doctors, Social workers and joint care managers. The environment is maintained to a high standard The kitchen achieved a 5 star rating from environmental health Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 6 We ensure that supervision and appraisals take place We provide a good level of social activity for the service users and some go out to Day centres. We have a high level of training courses for the staff and retain staff well. All staff are well trained and most are NVQ qualified We have a good reputation with professionals” This is a busy home but is always welcoming and provides a high level of care to people living at the home and their relatives. People said: • “on leaving after a visit I have always felt peaceful knowing she was surrounded by such loving and caring staff” • I always have confidence any issues raised will be managed” People said that they were well cared for and that staff knew how to look after them. The home operates at a good level with highly committed staff led by competent and capable managers. The managers have worked together at the home for a number of years. They provide stability and continuity for people living there and clear leadership to the staff. What has improved since the last inspection? The home continues to provide a high level of care to people living at the home. Information in the AQAA states: “Several improvements to the environment, new flooring to the main area and several bedrooms. More staff trained to NVQ 2 More resident/relative meetings Lifestyle plans have been improved.” There has been a lot of work to improve the environment with new furniture and fittings in bedrooms. More regular meetings are held with people to involve them in the running of the home and the planning of activities. Staff are trained to a high level so that they know how to look after people properly. Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 7 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. Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 People who use the service experience good quality outcomes in this area. People are provided with enough information to enable them to make an informed choice about the home. The admission process is good and includes introductory visits. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA states: “The staff have great understanding of the life changing decisions that the service user and their families have to make and work hard to make them feel comfortable. They ensure that the service user knows they still have choices Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 10 about their future after admission and we have a 6 weekly review to discuss if it is the right placement”. Everyone who is admitted to the home permanently has their needs fully assessed so that the home can be certain that their needs can be met. People are encouraged to spend time at the home before admission as part of this process. Information is gathered from a variety of sources and we saw the local authority care assessment and letters from other healthcare professionals in individual care records. Staff do understand the support people need when they move into the home and take time to get to know people. We saw this in the case of someone who had recently been admitted and who having trouble accepting that they needed care. Staff were understanding and sympathetic while working hard to get to know this person. There is a whole range of information freely available to people about the home, including the most recent inspection report. Some people are admitted for short term care and there are also good facilities for those admitted for intermediate care. Care staff are supported by the intermediate care team (ICT) in the interests of the rehabiliatation and promotion of independence of those people admitted for intermediate care. Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. Health care needs are met and care plans provide enough detail about care needs so that staff know how to look after people properly. People at the home are protected by safe medication practices. The staff respect the privacy and dignity of people living at the home. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA states: “Each service user has a keyworker who works closely with them on completing, developing and reviewing their individual care plan. All health needs are identified and met using outside professionals where Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 12 necessary including district nurses, dentists, opticians, OTs, physios, CPNs, orthotics etc Service users keep their own GPs where possible providing continuity of care Sensitive and needs led arrangements are made in the care of the terminally ill or dying service user. We liase with the service user, family, GP and other health care professionals to ensure that this is the best possible care for the service user and that between us we can meet their needs. We have input from the nursing team regarding end of life drugs and their administration when necessary. Several staff have attended courses on Death and Dying The home operates a safe and efficient medication system. Care staff administering medication heve the required training and follow the departments staff instruction”. The manager, senior staff and the carers know the people they look after very well and understand their care needs. Everyone at the home has a lifestyle plan that outlines the care and support they need. We looked at a small sample of individual records and saw that the daily records of care are all kept together in a ring binder and separately from individual care plans. This means that daily notes could be made and changes recorded without reference to care plans. This means that there is a risk that care could be overlooked. In addition, keeping personal information together in this way could be a breach of the Data Protection Act and should be reviewed. The manager and senior staff agreed with our comments and made the decision to replace daily records back in the individual files. The manager and senior staff on duty have a good grasp of the level of information needed in individual care records. They continue to work with care staff to support and guide them to make sure the detail in records reflects the good care people get at the home. All the records we looked at contained personal details about care and preferences. Night care plans give clear information about how to support people overnight. For example whether they like a light on and if they like a cup of tea if they wake in the night or when they wake up in the morning. A specific ‘bath sheet’ has been introduced and provides staff with detail about the support needed. For example, whether someone likes a bath with or without bubble bath and that one person now prefers to shower rather than bathe. There is also information for staff about what individuals can and cannot do. For example, whether people need help washing their back and legs. We saw that records are updated as needs and preferences change and also as staff build up knowledge about individuals following admission. Staff are vigilant at picking up changes in individuals and acting on them. For example, some people had nutritional problems and records were being kept of their Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 13 dietary intake so that clear evidence could be provided to other healthcare professionals if necessary. We saw clear information about the involvement of other healthcare professionals with, for example, clear records of visits made by the General Practitioner (GP). People said: “I always have confidence any issues raised will be managed” “…. will not always tell you when she is unwell but the staff do not miss anything” “dedicated and dignified care received during her final weeks at the home” “on leaving after a visit I have always felt peaceful knowing she was surrounded by such loving and caring staff” The home has good medication procedures in place and staff are given regular updates to make sure they have safe practices. There has been one medication error over the last year. The home took the correct action by informing the GP to make sure that the person was unharmed and the member of staff concerned was given additional training. Burley Willows Home For Older People DS0000033139.V372908.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 the service experience good quality outcomes in this area. People are able to maintain contact with family and friends and they are encouraged to be part of the decision making process at the home. A good, varied and nutritious diet that takes into account individual choice is served at the home. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Information in the AQAA states: “We provide a wide range of activities based on service user requests through resident meetings, care plans, reviews and activity feedback. We have motivation and exercise once a month, coffee morning with bingo every Wednesday, craft sessions once a week, prize bingo every Sunday, hairdresser every week, students from the university once a week in term Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 15 time to do quizzes, dominoes etc trips out etc We also pay for entertainment to come in. 7 service users go out to day centres Some service users go on holiday to the Waynes in Bridlington We have a payphone for the use of service users and some have had telephones installed in their bedrooms. Service users can choose where to entertain their visitors, either in the lounge areas, their own bedrooms, the visitors’ room or the garden. The chefs are qualified and experienced in cooking for older people. They know the individual likes and dislikes of service users, the special dietary needs etc Drinks and snacks are available 24hrs a day and all staff have access to food should the service users request something during the evening or night. Service users can choose to eat in their rooms if they wish. The menu is nutritious, well balanced and varied with plenty of choice. We have a summer and winter menu. We discuss food preferences at our service user and relatives meetings”. People are very much supported and encouraged to spend their time in the way they want to and to make their own choices. Those who are able to, go out regularly with family or friends. Staff also take people out wherever possible. Although there is no activities organiser at the home there is a range of regular weekly activities in place and one of the managers takes the lead in organising events and other entertainment at the home. She consults regularly with the people at the home about what they would like to do. Plans were already well under way in organising the programme of events for Christmas. The most recent event was a Halloween Party, which was enjoyed by many of the people living at the home. Other recent successful events have included themed evenings where the cook has also been involved in producing, for example, Italian foods for people to try and a Victorian Tea Party proved to be very popular with some staff dressing in authentic costume. Staff are sensitive to people’s needs and one person who was not feeling happy was offered an outing in a wheelchair with a member of staff, just before lunch, which she seemed to enjoy. One person who had only lived at the home for a short time told us that she really enjoyed the company of others as she had been lonely before moving in and said she was “quite happy”. Another person told us that “it’s not a bad place y’know” and that his daughter visited every day with her dog. Many other people also enjoy seeing the dog. Visitors are always welcomed and encouraged to join in events. Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 16 The kitchen is well run with the catering staff clearly taking a pride in their work. The winter menus have just been introduced. People are consulted regularly about the food they eat and given plenty of choice. The lunchtime meal was well organised and people were able to eat at their own pace with support given as needed. People told us that they enjoyed the food and that there was always enough to eat. Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 17 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 the service experience good quality outcomes in this area. There is a complaints procedure and people feel that any concerns will be taken seriously. People feel safe at the home. We have made this judgment using available evidence including a visit to this service. EVIDENCE: There is a comprehensive complaints procedure, which is displayed throughout the home, and the homes own quality assurance questionnaires results for 2008 showed that 97 of people living at the home said that they knew who to talk to if they had a any concerns. The staff survey indicated that the vast majority of staff felt confident that they could explain the complaints procedure to people. A log is kept of any complaints and of compliments received. There is a low level of complaints received. One complaint had been received at the home in the last twelve months and this had been resolved within the timescales set by the provider. The number of compliments received continues to be high. Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 18 All the senior staff at the home have received training in safeguarding and the training is ongoing for all staff. Information provided in the AQAA states that there has been one safeguarding referral in the last twelve months. Staff training is also ongoing regarding the Mental Capacity Act 2005. Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 19 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 the service experience good quality outcomes in this area. People live in a safe, comfortable and well-maintained environment. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA states: “The home is clean, well lit and odour free The kitchen meets all health and safety and environmental health requirements and we have received a 5 star rating. Health and safety checks are done monthly by management staff and thay Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 20 have all done the 5 day IOSH training The environment is maintained to a high standard, we report repairs promptly and followed up to ensure speedy repairs. All electrical equipment is PAT tested annually The environment is adapted for older people and people with physical disabilities, it is all on one level. We have a selection of small, comfortable lounges all with TVs All bedrooms have emergency call bells within easy reach of service users when in bed and extension leads are provided if needed. Bathrooms are modern and comfortable with assisted baths and showers, all the equipment is serviced annually. The home has a sprinkler system, fire bells are tested weekly, fire drills are done regularly and all staff have had fire training All taps in bedrooms and bathrooms have safety valves on to prevent scalding The home has a small, enclosed garden with tables, chairs and umbrellas. The flowers and tubs are looked after by the staff”. All the areas of the home that we visited were clean tidy and fresh smelling. Last year an application was made to the local authority for a dignity grant which has been used to upgrade the bedrooms, installing new vanity units, wardrobes and chests of drawers. This work will be completed with the delivery of soft furnishings for all the bedrooms. People told us how pleased they were with the improvements to their rooms. There are plans in place to continue the environmental improvements with more bedrooms to be decorated and more furniture to be replaced. Although there are no ensuite facilities the communal bathroom and toilet facilities are spacious and allow for full assistance if needed. There is a comfortable designated lounge for the use of smokers who live at the home. West Yorkshire Fire Service have completed a fire safety inspection earlier this year and the indentified shortfalls are to be addressed over the next twelve months. Staff have regular fire training including taking part in fire drills. The majority of staff have had training in infection control and good practices were observed. Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 21 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 the service experience good quality outcomes in this area. Trained and competent staff look after people. People are protected by robust recruitment procedures. We have made this judgment using available evidence including a visit to this service. EVIDENCE: Information in the AQAA states: “We have a high emphasis on training and the staff are keen to go on courses We have a low turnover of staff We do not use agency staff for personal care NVQ levels are at 99 The qualifications of the managers and senior staff meet national requirements We have a good supervision and appraisal system in place Recruitment is highly selective. We re-advertise if we do not interview the right person”. Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 22 There were enough staff with the right skills to look after the people living at the home and the care staff were well supported by a team of ancillary staff. Care staff also said that they were well supported by the management team. They told us about formal supervision and the training opportunities provided. Staff know people very well and are patient and caring in their approach. People said: “Your staff are 100 genuine, they are caring and are really quite passionate about the home”. “The staff are always on their toes” “Staff are informative and helpful” “Staff are kind caring and patient” Recruitement practices are good and all the required checks are carried out before staff start work at the home. Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 23 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 the service experience excellent quality outcomes in this area. The home is well managed and the managers are well able to discharge their responsibilities. They provide excellent leadership to the staff and ensure that people living at the home are protected and cared for appropriately. We have made this judgment using available evidence including a visit to this service. EVIDENCE: There are two experienced and capable managers who ‘job share’ the position of registered manager. This is an effective arrangement and they provide clear Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 24 leadership and stability at the home. Both managers are well qualified and have completed the Management Charter Initiative and also hold an NVQ in care at level 4. They continue to strive to make sure that they maintain and improve their own skills as well as those of the staff team. The AQAA had been completed to a high standard and had again provided the opportunity to review the service objectively. An action plan had been produced to address the issues they had identified as needing attention to improve the service. This reflects the continued proactive style of management demonstrated previously by both managers and a commitment to the continued development and improvement of the service provided to people at the home. The people living at the home, their relatives, the staff and visiting healthcare professionals are surveyed annually. The results are made available to people and show a positive view of the home. Where shortfalls have been identified an action plan had been produced and made available the managers had developed a plan to address them. Feedback from surveys completed by people living at the home in 2007 showed that they did not feel involved in decision making at the home. As a result more regular meetings are held with people living at the home and their relatives. Managers are accessible to people living at the home and their relatives through their ‘open door’ policy. Regular in house care reviews are also held giving people and their relatives the opportunity to discuss care and any concerns they might have about the service provided. Staff meetings are held regularly and there is a programme of formal supervision in place to provide support for staff. Information provided in the AQAA states: “All senior staff have attended 5 day IOSH training and ensure the well being of staff anservice users including monthly health and safety checks, maintenance of all equipment, fire tests and drills and fire training. We have a low level of staff accidents and injuries. We have an open door policy and good relationships with families and professionals. Records of financial matters are maintained within departmental and audit procedures. Supervision and appraisal systems are in place. Excellent staff care facilities including special leave, flexibility, access to counselling, physio etc The managers ensure that improvement is always taking place including the daily life of the service users, training, the environment etc Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 25 The managers are continually looking at their own professional development to ensure their skills and knowledge are up to date”. The home do not act as appointees for people living at the home and do not handle anyone’s money, other than a small amount of personal allowance for incidentals. These procedures are subject to regular in-house checks and external audit. Burley Willows Home For Older People DS0000033139.V372908.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 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 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 28 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 Burley Willows Home For Older People DS0000033139.V372908.R01.S.doc Version 5.2 Page 29 - 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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