Care Home: The Willows

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What the care home does well This is a new service. The property is newly renovated and people living at the home are benefiting from a property which both meets their needs and provides living accommodation which is spacious and has been finished and furnished to a very high standard. People wishing to live at the home are assessed well and this assures them that the service is aware of their needs and is confident it can meet those needs when it offers care and accommodation. Care planning and monitoring systems are robust and staff are very familiar with the goals of people living at the home. The Inspector observed staff engaging service users in their planned therapeutic programmes. Staff have a very good understanding of brain acquired injury. This supports people living at the home to achieve their goals and to make tangible progress. This is achieved in clear partnership between staff and people living at the home and there is an up beat and positive atmosphere based on mutual respect. Service users are supported to be independent and staff are very clear about their role in promoting independence. Service users do not have any complaints but are supported to know how to complain should they need to and are confident their concerns would be listened to and acted upon. Professionals involved with the home who responded to CSCI`s survey hold it in high regard. A social worker said ``I have been very impressed with the skill and commitment of staff. They have worked out clear and realistic goals with X and consistently help him to achieve these. They appear firm but fair and always encouraging although not afraid to correct X and remind him of his goals. I wish other of my ABI clients could have same high input`. What has improved since the last inspection? This is a new service and this is therefore the service`s first inspection. CARE HOME ADULTS 18-65 The Willows 57 High Street Madeley Telford Shropshire TF7 5AT Lead Inspector Deborah Sharman Key Unannounced Inspection 12th June 2007 09:00 The Willows DS0000068830.V336384.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 The Willows DS0000068830.V336384.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. The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Address 57 High Street Madeley Telford Shropshire TF7 5AT 01952 272392 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) Prokare Limited Mrs Amanda Helen Woolley Care Home 8 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (8) of places The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is a new service Brief Description of the Service: The Willows is a newly renovated detached modern house which is domestic in style and which was registered as a Care Home with the Commission for Social Care Inspection on 10 January 2007. The property is set back from the bottom of Madeley High Street and therefore is private and not overlooked but enjoys easy pedestrian access to the High Street facilities. There are eight single bedrooms, some of which are on the ground floor and some have en suite facilities. There is also a large communal lounge / dining room, a smoking room and a quiet room, a ground floor toilet and separate shower room, a separate communal bathroom and a hoist is available for people requiring support with moving and handling. A lift is available to help people to access the first floor. All bathing and toilet facilities have grab rails. The property also has gardens for people living at the home to access and develop if they wish to. Fees: The weekly fee is 1328.00 per week. This includes all food, accommodation and therapy. Personal effects are paid for in addition and where a one to one staffing ratio is required to meet need this is charged for in addition to the flat fee. The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a newly registered service and therefore this was its first inspection. The inspection, which was carried out by one Inspector over seven hours between 9.15 and 16.15, was unannounced. This means that no one associated with the service received prior notification and were therefore unable to prepare. This inspection was also a key inspection meaning that all significant areas affecting outcomes for service users were assessed. Information to support the judgements made by the Inspector about the quality of the service provided was collated in a number of ways. Prior to inspection the service was required to submit information to The Commission for Social Care Inspection (CSCI) about the quality of its service. CSCI also sent a number of questionnaires to people receiving a service from The Willows and others associated with it such as relatives and professionals. On the day of inspection the Inspector was able to tour the premises, talk in detail to people living at the home about their impressions of the service, talk to staff in detail, assess care documentation for two people receiving a service and assess other documentation which indicates how the home is being managed. The Manager was unavailable on the day of inspection but the Regional Service Manager was available throughout the day to support the inspection process. There are two people living permanently at the home currently. Both are male. Other people all of whom are male have received a respite service and at the time of inspection a third resident was enjoying a months respite there. Everybody was very welcoming and cooperated fully with the inspection and thanks are extended to all those involved. What the service does well: This is a new service. The property is newly renovated and people living at the home are benefiting from a property which both meets their needs and provides living accommodation which is spacious and has been finished and furnished to a very high standard. People wishing to live at the home are assessed well and this assures them that the service is aware of their needs and is confident it can meet those needs when it offers care and accommodation. Care planning and monitoring systems are robust and staff are very familiar with the goals of people living at the home. The Inspector observed staff engaging service users in their planned therapeutic programmes. Staff have a very good understanding of brain acquired injury. This supports people living at the home to achieve their goals and to make tangible progress. This is achieved in clear partnership between staff and people living at the home and there is an up beat and The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 6 positive atmosphere based on mutual respect. Service users are supported to be independent and staff are very clear about their role in promoting independence. Service users do not have any complaints but are supported to know how to complain should they need to and are confident their concerns would be listened to and acted upon. Professionals involved with the home who responded to CSCI’s survey hold it in high regard. A social worker said ‘‘I have been very impressed with the skill and commitment of staff. They have worked out clear and realistic goals with X and consistently help him to achieve these. They appear firm but fair and always encouraging although not afraid to correct X and remind him of his goals. I wish other of my ABI clients could have same high input’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. The Willows DS0000068830.V336384.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 The Willows DS0000068830.V336384.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): 1, 2, 3, 4 Quality in this outcome area is good. Service users feel they were involved in the decision to stay at The Willows and feel they had sufficient information to support them to do this. Service users are satisfied that their needs are met and that they are being supported to achieve goals and make progress with their rehabilitation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All admissions to the home have been planned admissions. This provided sufficient time for assessments to be carried out and service users to be offered the opportunity to visit. Some chose not to as they were familiar with other ProKare services. Good assessment systems are in place and the information obtained is used well to plan interventions to meet service users’ needs. One service user confirmed he had been visited at home by staff who visited him before offering him a service. He also said that he feels staff know him well enough to meet his needs. A further service user confirmed in writing to CSCI that he had been consulted about moving to the home and had received enough information to make an informed choice about this. The Inspector spoke to two of three service users accommodated. Both were very happy that their needs are being met with one service user saying he The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 10 feels ‘whole again’ after having made significant progress towards independence and well being. The Willows DS0000068830.V336384.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): 6, 7, 9. Quality in this outcome area is good. Robust care planning and monitoring systems are in place to ensure that service users’ assessed needs are met. Staff remind service users what their goals are but service users make the final decision about how they lead their day to day lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A care plan is in place for each resident based upon their assessed needs, aspirations and risks and the systems to monitor it are very robust. A staff member was able to very clearly explain the system to the Inspector and demonstrated a clear working knowledge of service users needs and strategies in place to meet those needs. The Inspector observed a second staff member on duty carrying out the planned intervention in accordance with the plan of care and the service users wishes. He reported being pleased with his achievements at the end of the morning programme. The programme was observed to be intensive but fun. Service users’ achievements are plotted on The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 12 a graph. This gives service users a visual tool with which to appreciate their progress and it serves to provide additional motivation. Plans, goals and achievements are kept under close review and associated professionals are involved where possible in the review process. Risks are identified for individual service users, are documented and are known to staff. Systems are in place to minimise risks but service users are enabled to take appropriate risk to promote their independence and rehabilitation. For example, one service user was very pleased that for the first time he had travelled independently by train to his hometown for the weekend. Another service user was being supported to meet goals that he was finding difficult. Goals had been set for the day but his wishes were ultimately respected when he decided to leave the challenge for another day. A service user said ‘‘I always get to decide what I would like to do. I like to go out independently. But I always complete cognitive and physical exercises’ Advocacy services are available and have been used by service users. A social worker in response to CSCI’s survey said that the home appears to meet individual’s diverse needs. The Willows DS0000068830.V336384.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): 12, 13, 15, 16, 17. Quality in this outcome area is good. Service users enjoy their lifestyles at The Willows, which provide independence and challenge in accordance with their assessed interests and needs. They enjoy their meals, which they help to plan and prepare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff know the interests of people who live at the home and one service user told the Inspector how he has hobby equipment with him to pursue. Service users spiritual needs are known and are assessed. None currently choose to practice a religion. Activity plans are tightly scheduled with therapies, hobbies, community visits, domestic tasks and rest periods being timetabled daily. Service users confirmed that they agree these in advance and they are followed flexibly The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 14 throughout each day. Service users confirmed that they take responsibility for cleaning their own bedrooms as part of their rehabilitation and a service user who enjoys cooking said he regularly helps with meal preparation. One service user had been away independently for the weekend and had met up with friends he had not seen for a long time. This service user has also made friends locally by eating at a local restaurant sometimes alone and at times accompanied by another service user from The Willows. There was also evidence that contact with family is encouraged and supported where it is the service user’s wish. A service user has told the Inspector that he would like the home to get some transport and this has been discussed in service users meetings. Service users are happy with how their mail is managed, confirming it is passed to them unopened. Service users also have keys to their bedroom doors to use should they wish to do so. A Service user praised the meals with one person saying he regularly shops for food with staff and is able to choose food items whilst shopping. He and staff independently confirmed that menus are designed in consultation with people who live at the home based upon their preferences and that alternative meals are available should the planned meal not meet with a service users preference. The Inspector ate lunch with service users and it was a relaxed and sociable occasion. Snacks and drinks are always available to which service users help themselves. Currently no service users have any special dietary requirements but one service user who is concerned about his weight is booked to receive medical advice about this and records show that he is making progress which he is pleased with. The Willows DS0000068830.V336384.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): 18, 19, 20. Quality in this outcome area is good. People who live at the home can be assured that their personal care and health needs are met. Their independence is promoted and their wishes are respected. This promotes their dignity and their rehabilitation. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users receive support with personal care proportionate to the level of support they need. Service users are encouraged to be as self-caring as possible and advice from a physiotherapist has helped one service user to achieve independence. Service users spoken to were satisfied that their needs in this area are met well and staff spoken to demonstrated a good working knowledge of service users needs and preferences. Staff reported feeling competent to use equipment available to support moving and handling where required. The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 16 The home operates a key worker system with both service users and staff having a good understanding of the role. A staff member said she feels that this is key to supporting service users and the effective management of the home. A service user told the Inspector that he likes The Willows because ‘it is not regimented’. There was good evidence that service users are supported to attend routine and individualised health screening appointments. Medication is managed well with service users having no concerns. Independence is again encouraged in this area with subject to risk assessment self-administration taking place where practicable. A social worker has told CSCI that the home ‘always supports service users to administer their own medication or manage it correctly where this not possible.’ The Willows DS0000068830.V336384.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): 22, 23. Quality in this outcome area is good. People living at the home have no complaints but are satisfied their concerns would be listened to and responded to. Systems are in place to ensure that people living at the home are adequately protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints have been made. Due to memory loss associated with acquired brain injury, systems are in place to inform service users upon admission of the complaints procedure and to remind them six monthly thereafter. This is documented. Residents said they know how to complain if need be and were able to explain that they would raise any issues in first instance with their key worker unless the complaint was about their key worker when they were aware of alternative options available to them. In addition, written complaints procedures are in place and are also within the Service User Guide. The Manager must ensure that CSCI’s contact details are updated within this document to ensure service users can easily access the home’s regulator should they need to. Service users are listened to at service user monthly meetings and their comments are recorded in detail to ensure that issues can be addressed before they become complaints. A service user at a recent meeting for example requested gardening equipment and plans are in place to purchase this. The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 18 Service users are protected by robust systems. Not all staff have undertaken adult abuse training but the subject is covered at induction and a new member of staff spoken to had a good understanding of the issues and her role in the event of their being a concern. The staff member said she feels that service users are very safe at The Willows. Adult protection training is currently under review and the plan is to include anger management training within this. Behaviour support plans are in place based upon positive principles where required. There have not been any allegations or incidents or physical restraints of service users. Appropriate written guidance is available to support management and staff in the event of any concern involving a vulnerable adult. A service user spoken to is satisfied with how his money is held and managed. Appropriate records are in place that account for income and service users countersign expenditure and records. Staff and service users check money together daily. ProKare is receiving monies for one service user from an external source in a cheque that is paid into the Organisations business account at head office. This is supplied weekly to the service user in a cheque by head office but it is contrary to the regulations for money to be pooled in a business account. Staff explained that the Manager is aware of the need to review financial systems overall for this service user and are confident that the issue will be addressed as part of the overall review. The Willows DS0000068830.V336384.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): 24, 30. Quality in this outcome area is excellent. People at The Willows live in pleasant and homely accommodation that has been renovated to a very high standard and that meets their current needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises showed them to be homely, domestic, very clean and renovated and furnished to a very high standard. A service user said ‘it is a very clean place’. Service users feel at home and stated that they can relax in the communal areas of the home. Service users reported enjoying and developing the gardens. Ground floor accommodation with adaptations is available to meet the needs of people who use wheelchairs. Service users reported individualising their bedrooms and security has been considered through the provision of window locks, covered radiators to prevent burns, door keys for service users and the availability of lockable storage facilities, within bedrooms. Temperatures of water outlets are also taken regularly and The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 20 recorded to monitor their safety. Freezer temperatures need to be reviewed as records showed them to be 15 and 16 degrees, which is too warm. It is important that staff react quickly to this to prevent the risk of food borne illness. Laundry facilities are appropriate and clean and colour coded systems are in place to prevent cross contamination. Staff demonstrated a good understanding of how to maximise infection control. Environmental risks including those posed by hazardous chemicals are identified with control measures in place to reduce acknowledged risk. These are due for review imminently. A service user provided this written comment for CSCI about the homes premises: ‘‘The Willows is a nice, new, well-equipped house set in pleasant gardens. My room is ensuite, spacious and comfortable.’ The Willows DS0000068830.V336384.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): 32, 33, 34, 35, 36. Quality in this outcome area is good. Staff are inducted thoroughly to prepare them for their role and training thereafter is available. The provision of training to staff in aspects of Acquired Brain Injury is particularly good and assures people living at the home that staff are supported to understand their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff are well motivated, committed and demonstrate themselves to be competent. Good induction and support systems promote this and staff spoke highly of training available in aspects of acquired brain injury. Staff particularly spoke highly of the support available to them from the manager and attributed the homes positive outcomes to her educative focus and role modelling. Not all training documentation was available and must be for following inspections. However the extent of staff knowledge and service user satisfaction demonstrated during the course of the inspection provided good evidence that outcomes for service users are being met and that there are no concerns about the competence of staff. A social worker that provided CSCI with feedback spoke highly of the staff approach perceiving it as highly The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 22 effective. A service user said ‘staff always treat me well. They are friendly and nice. Staff always listen to me and do their best for me’. Another service user said ‘The staff are fun as well as professional and I’d feel comfortable taking any issues to them. The rotas are well maintained and show 2 staff to be on duty at all times with the Manager being supernumerary. Good systems are in place to provide on call support to staff out of hours. Staff work long days over 3 days per week but reported this as an opportunity for consistency. Two new staff have recently been recruited to provide waking night cover and are waiting clearance before taking up post. This will reduce the need for agency staff cover and provide greater continuity. Staff files were not sufficiently available for inspection. Only information appertaining to the Manager and a second staff member were available. Information appertaining to the most recently recruited staff was not available and therefore how safely they were recruited could not be assessed as planned. The file available for a staff member recruited a year ago that transferred from another of ProKares’ homes was assessed and all aspects of process were found to be satisfactory and to protect service users. The Willows DS0000068830.V336384.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): 37, 39, 42. Quality in this outcome area is good. Staff and service users have confidence in the management of the home. They feel that the service is managed in the best interests of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A staff member said ‘I think the home is run fantastically well. It runs like clockwork. Everyone is aware of their role and how the roles fit together. There are good relationships between staff and management. It’s the way the Manager trains people. I knew nothing about brain injury before I came here.’ When asked what the home does well the staff member added ‘ I think we are fantastic at rehab. We are good at identifying needs when service users come The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 24 to us. Teamwork is fantastic and we don’t work against each other. The systems give a uniformed approach. We are good at promoting independence. I don’t do things that clients can do. We are good at adapting to what clients need. Clients here don’t have to fit in with us. We help them to help themselves. It would be ideal for them to go back to the community and live independently’. The outcomes of this inspection absolutely confirm the opinion of this staff member. Two staff members confirmed receiving regular support meetings with their manager, which look at their needs as staff members. They talked also of attending objectives meetings individually with the manager where service users objectives are discussed and reviewed. Not all maintenance and service records were available on the premises. The Inspector was told that this was because CSCI had returned them during the registration process to head office who had not yet forwarded them to the home. However at this point the buildings and its facilities are new and present as low risk. Two staff members reported no concerns with the management of requests for repair and maintenance. A handy person is employed who the home can access when required they said. All records including staff recruitment and training must be available on the premises. Water temperatures, hot food temperatures and fridge and freezer temperatures are being taken and recorded. As mentioned before freezer temperatures need review as records show them to be too warm without an appropriate response by staff. A First aid box is available and some staff are first aid trained. The Fire Service inspected the home in March 2007 and found matters to be satisfactory. Corporate quality assurance systems that seek service user feedback are in place and the plan is to distribute these once the home has become more established. These surveys are designed to be annual and to date the home has been registered for 6 months. The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 25 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 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 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 X 3 3 X 3 X 2 3 X The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 26 N/A 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 YA23 Regulation 20(1) Requirement To protect the financial interests of service users the registered person must not pay money belonging to any service user into a bank account unless: The account is in the name of the service user to which the money belongs; and The account is not used by the registered person in connection with the carrying on or management of the care home. Requirement arising from this inspection June 2007. Timescale for action 30/09/07 2 YA41 17(2) Sch 4 (6) All records required by regulation 31/07/07 must be available on the premises and must be available for inspection. This will better enable management planning and assessment of performance to safeguard service users interests. Requirement arising from this inspection June 2007. 3 YA42 13(3) Systems must be in place to effectively safe guard service users from the risk of toxic DS0000068830.V336384.R01.S.doc 30/06/07 The Willows Version 5.2 Page 27 conditions which may arise from food borne illness as a result of none compliance with safe cold storage temperature ranges. Requirement arising from this inspection June 2007. 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 The Willows DS0000068830.V336384.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 The Willows DS0000068830.V336384.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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