Care Home: The Willows

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What the care home does well The service provides very individual and personalised care in a relaxed and homely manner. The staff were seen to be attentive and caring to the residents and respected them as individuals. The equality and diversity of residents was promoted by everyday practises and the staffs ability to see beyond the disability. The routines in the home are flexible to suit the needs of the individuals. Records are well maintained and staff have a good understanding of confidentiality. Residents enjoy a good level of activities arranged by the staff and now have the use of two minibuses. What has improved since the last inspection? A new cooker and fridge have been supplied to the kitchen and the home also has a new boiler fitted. A second minibus has helped with outdoor activities although obtaining a driver is sometimes a problem. All residents now have single rooms. What the care home could do better: The inspector was disappointed to find that staff seemed unaware of the cold temperatures in the bedrooms but does note that immediate action was taken. The same applies to the residents whose water had been turned off. The requirement regarding new furniture had not been fully complied with and this appears to be taking an inordinate amount of time to complete. The manager confirmed Occupational Therapy assessment had started in 2005 and two residents have still not been assessed. The Trust must ensure these are undertaken and the results put into action. It will be a requirement that more staff be employed so that the dependency on agency staff can be reduced to ensure continuity of care for the residents. CARE HOME ADULTS 18-65 Willows (The) The Willows 40 Searchwood Road Warlingham Surrey CR6 9BA Lead Inspector Sue McGrath Unannounced Inspection 20th November 2007 10:00 Willows (The) DS0000013832.V349738.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) DS0000013832.V349738.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) DS0000013832.V349738.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willows (The) Address The Willows 40 Searchwood Road Warlingham Surrey CR6 9BA 01883 627747 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) rajesh.doorga@sabp.nhs.uk Surrey and Borders Partnership NHS Trust Rajeshwarsingh Doorga Care Home 10 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (2), Physical disability (5) of places Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 10 (ten) people with learning disabilities (LD) accommodated, 5 (five) will have an additional physical disability (PD). 04/07/06 Date of last inspection Brief Description of the Service: The Willows is owned and managed by Surrey and Borders NHS Trust. It is currently registered to provide residential care for up to 10 adults with learning disabilities, some also have physical disabilities. At the time of this inspection the home had only 8 Service Users in residence. The home is a large converted detached property and is located in a quiet residential area within the village of Warlingham. The accommodation for Service Users is provided on two floors, with all single bedrooms. The communal space is provided in one good size dining room, a lounge and one room equipped with sensory equipment. Service users have access to a large enclosed garden at the rear, which was laid out in lawns with an area of enclosed trees at the rear boundary. The home has parking space within the forecourt as well as space for the home’s two minibuses. Fees: £1114.78p per week. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place on 20th November 2007 and was conducted by Sue McGrath, Regulation Inspector for the Commission for Social Care Inspection. The key inspections for care home services are part of the methodology for The Commission For Social Care Inspection, whereby the home provides information through a questionnaire process and further feedback is gained through surveys sent to service users and relatives and information provided from professionals associated with the home, wherever possible. The actual date of the site visit is unannounced. At the site visit, service users and staff were spoken to, records were viewed and a tour of the environment was undertaken. Some judgements have been made through observation only. The requirement made at the last inspection had not been fully complied with. Overall this was a positive inspection with generally good outcomes for service users. The inspector on leaving the home was satisfied that residents were both safe and well cared for. The inspector would also like to thank the residents, registered manager and staff members for their time, assistance and hospitality during the site visit. What the service does well: The service provides very individual and personalised care in a relaxed and homely manner. The staff were seen to be attentive and caring to the residents and respected them as individuals. The equality and diversity of residents was promoted by everyday practises and the staffs ability to see beyond the disability. The routines in the home are flexible to suit the needs of the individuals. Records are well maintained and staff have a good understanding of confidentiality. Residents enjoy a good level of activities arranged by the staff and now have the use of two minibuses. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 7 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) DS0000013832.V349738.R01.S.doc Version 5.2 Page 8 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 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents and/or their representative are not fully provided with the information they need to make an informed choice about where to live prior to admission. They are provided with a statement of terms and condition of residency. Residents and /or their representatives can be confident assessed needs can be met EVIDENCE: The home has a statement of purpose but the manager is currently updating this. He is strongly advised to refer to Schedule One of the Care Standards Act 2001 to ensure the final document complies fully. It is also his intention to improve the pictorial content. The service has not admitted any new residents since the last inspection and the actual registered number has been reduced to 10. Currently the home has 8 residents. The manager was able to fully discuss the admission process that would be used should the need arise. This process when followed would ensure all needs are fully assessed prior to admission. Prospective residents would Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 9 only be admitted if the home were certain their aspirations and needs could be met. The manager confirms that each resident has a written contract with terms and conditions with the home and that this has been agreed with the resident’s representative where possible. All of the residents have been admitted via Social Services and have a dedicated Care Manager. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6. 7. 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have clear and in-depth care plans that identify their individual needs and give clear guidance to staff. Care plans are regularly updated to ensure changes are recorded and acted upon. Residents are enabled to take reasonable risks within the homes risk assessment management strategies. EVIDENCE: Each resident has a clear, individual care plan that reflects his or her personal needs and aspirations. Each resident has a H.A.P. (health action plan) and P.C.P (person centred plan), which are reviewed by the individual’s key worker on a regular basis. Formal six monthly reviews are also undertaken. Staff confirm they are fully involved with these plans and take their responsibilities seriously. Each care worker receives training on how to support each resident in order to develop a clear picture of the persons needs. The residents at the Willows have profound needs and rely heavily upon the assistance of regular care workers to meet even their most basic of needs. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 11 Staff are aware of how each residents is able to communicate and how best to support them to do so. Different methods include the use of Maketon, picture formats, body language and facial expressions. Staff confirm they feel confident they are able to communicate sufficiently and endeavour where possible to assist residents to make personal choices. At the time of the inspection the inspector was unable to obtain direct feed back from the residents because of their complex disabilities and inability to communicate verbally. The inspector was however able to gather evidence by direct observation which indicated that staff understood the needs of the individuals and were able to support them effectively. The taking of risks amongst the residents was discussed and it was evident that where possible emphasis is given on ensuring a safe environment but it was also evident those daily activities are not hindered by too many restrictions. Evidence of risk plans was seen on resident’s files. Staff receive training on confidentiality during their induction period and staff are aware of its importance and respect residents personal information and data. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 12 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): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from having the opportunity for personal development with their daily living skills and have appropriate level of leisure activities. Residents also benefit from being part of the local community. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. EVIDENCE: The manager explained that the residents used to attend the local day centre on a daily basis but recently the number of placements available had been reduced. This has meant that residents can only attend approximately twice a week. This has meant that more activities have had to be provided by the home. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 13 Some residents miss the daily contact with some of their peer group but the staff have endeavoured to arrange a variety of activities to suit each individual. These range from swimming, cookery, trips to the local pub, walks out and trips to the shops. This is not an exhaustive list of activities. Some are done as group activities and some as individual activities. The key workers are responsible for arranging the activities and for ensuring the residents participate in activities they enjoy. All activates are recorded on a daily basis. All residents have individual bus passes and their own passports. Some residents have regular family visits and one has an advocate. Residents are encouraged to make friends and some show a level of affection for each other. The choice of whom they wish to make friends with is respected. Each individual is treated as an individual and his or her diverse needs are well respected. Equality and diversity is at the heart of all the practises in the home. Each individual develops at their own pace and time, taking into consideration the level of functioning and disabilities. Some residents are able to participate in household chores and domestic activities and to assist in task orientated activities to their own rooms. Some are able to assist preparing and serving meals. Staff were seen to respect privacy and dignity when offering personal care. Residents are offered a healthy diet and appeared to enjoy their lunchtime meal. The home has input from a dietician when devising the daily menus and staff are aware of personal likes and dislikes. Meal times are flexible to suit the needs of the residents and take into account the relevant activities on that day. The kitchen is clean and tidy and all appropriate records are well maintained. Evidence was seen of fresh fruit and vegetable being readily available. The home now has two minibuses available for residents to use. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health needs are met and resident’s benefit from having full access to all professional health care services as required. Residents are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Staff were seen to provide sensitive and flexible personal care taking into consideration privacy, dignity and the promotion of independence. Residents wishes are respected and if they refuse to cooperate the reasons are documented and the task would be deferred until the resident wishes to participate. Physical health needs are well met and every effort is made to meet emotional needs. All residents are registered with a local G.P. and other professional health specialists are involved according to need. The G.Ps. undertakes annual Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 15 health checks and the Trust has a Consultant Psychiatrist when needed. Urgent referrals are made to the G.P for any ailments and illnesses. Residents have been assessed by an Occupational Therapist for specialist equipment and furniture. The equipment is mainly in place but the furniture is slow in arriving. To date one chair and one bed have been provided. The manager did say this process had taken a long time to complete due to budgetary restraints. The furniture has now been ordered and delivery is expected soon. This was a requirement from the last inspection and although it is recognised that work has been ongoing the requirement will remain in place until the furniture is in use. The Occupational Therapist also recommended that the current Parker bath does not meet the needs of the residents. A specialist bath has been costed and the manager is awaiting permission for the bath to be purchased. Due to the level of disability in the home residents medication is administered by senior staff, who have all received training from the Trust. The home uses a monitored dosage system and the administration records are well maintained and accurate. Medication is stored appropriately. One area slight of concern was that some residents written medication information did not reflect the actual prescription from the G.P. This needs to be updated to reflect what is the current medication and dosage. There are sound systems in place to ensure the system is monitored for accuracy. The home handles the care of residents with epilepsy well and monitors any seizures to identify patterns and to ensure the safety of the individual resident. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All required policies, procedures and practices are in place to ensure that residents are safeguarded, as far as reasonably possible, from harm or abuse. EVIDENCE: The service has a complaints policy, which is contained within the service user guide and the employee’s handbook. Staff confirmed that local advocacy, interpreters or communication support workers, would be provided to residents who want to express their views or to make a complaint. Under the Trusts Zero Tolerance Policy the residents and their families can be assured they will not be victimised for making a complaint. Where a resident lacks capacity to understand any issues or make an informed choice, the home arranges for multi-agency procedures to be put in place. All staff have attended the safeguarding of vulnerable adults training and when spoken with by the inspector it was evident they were aware of the whistle blowing policy. There have been no complaints made directly to the CSCI and a review of the complaints log would indicate that there have been no formal complaints made to the service since the previous inspection. One informal complaint was made by a neighbour and dealt with promptly by the manager. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 17 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, 25, 27, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a homely environment and all have single rooms. Residents do not benefit from having suitable equipment and furniture to meet their assessed needs. The home is clean and hygienic. EVIDENCE: On the day of the inspection the home was clean and fresh but the first floor was cold with the radiators not working. The upper bathrooms were also cold. When this was queried with staff they did not appear to realise how cold it was. The maintenance department was contacted and visited within a few hours. The system needed bleeding and was functioning before the end of the Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 18 day. The concern is why this had not been addresses by the home prior to the inspection. One of the bedrooms does not have any washing facilities as required by regulation and the manager will be required to assess the situation and inform the Commission of the reason why no washing facilities are available. Another of the bedrooms had a sink but the water supply had been turned off for no apparent reason. No one appeared to be aware that water was not available in that particular room and again this causes concern. It was unclear how residents personal hygiene and infection control are addressed with regards to hand washing and cleaning the sink. Once the problem was highlighted to the manager the engineers on site also turned the water back on. There was no evidence of who or why the water had been disconnected. The requirement made at the last inspection regarding furniture has not been fully complied with as mentioned earlier in the report. It is recognised that work is ongoing but has taken an inordinate time to be completed with residents still having to use inappropriate furniture. The Registered Manager gave assurances on the day and the Inspector has no doubts as to his good intentions regarding the full compliance with this requirement. The requirement will remain until fully met. The bathrooms are spacious but one of the baths is not appropriate to meet the needs of the residents as confirmed by an Occupational Therapist. A requirement will be made to ensure appropriate bathing facilities are provided. It is recognised that a quote has been obtained but this now needs to be funded and provided. All of the residents now enjoy single rooms and this has had a positive effect on the residents who used to share. The manager described the positive effect on the behaviour and progress of the residents who used to share. The home has sufficient adapted toilets to meet the needs of the residents. The communal areas of the home consist of a lounge, separate dining room and kitchen. There is also another small sitting/relaxation room also used as a quite area. A new fridge and oven has been fitted in the kitchen this year. A new boiler has also been installed. It was discussed with the manager at the last inspection that the furniture used in the communal areas was inappropriate in view of the residents physical needs in addition the upholstery fabric is not easily cleaned and hygiene standards and infection control could be affected. This has not changed and the furniture remains the same. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents’ benefit from being cared for by staff who have a good understanding of their needs. Staff shortages mean that the home is understaffed. Residents in the home benefit from the support of carefully selected and trained staff who understand their needs. EVIDENCE: Staff recruitment files are up dated and contain all the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001. All staff have a criminal record bureau (CRB) check and Protection of Vulnerable Adult (POVA) check prior to starting work in the home. The number of staff on duty and the mix of trained and care staff was seen to be satisfactory to the assessed care needs of service users in the home. The home currently has three full time vacancies for care support workers and this means that a high number of agency staff are used. Although the manager Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 20 does try to use the same agency staff, this cannot be guaranteed, and with the complex needs of the residents this cannot be seen as good practise. The home has covered 191 shifts with agency staff in the last three months. It will be requirement that sufficient staff to meet the resident’s need to be employed. Staff training is undertaken and seven of the twelve staff have completed a National Vocational Qualification to Level Two or above. Currently two staff are working towards their award. Mandatory training is arranged through ‘Joint Training in Surrey’ part of the Trust; however there is a problem with evidencing this training has actually taking place, as currently the company has not supplied certificates of competence/attendance. The manager can evidence that an application to attend training has been made, but not that the training has been completed. The inspector does not doubt the training took place, but the home must be able to evidence this and must ensure the training organisation produces the evidence. Staff also commented on how disappointed they were not to receive the relevant certificates. Evidence was seen that all new staff undertake a full an induction programme, which is covered over several weeks. This was also confirmed by staff. Staff receive regular supervision and confirm they feel well supported by their management team. Yearly appraisals are also undertaken. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 40 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from living in a home where the manager is competent, enthusiastic and experienced with the care of people with complex needs and has a clear vision for the home. The health, safety and welfare of residents and staff is promoted and respected. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 22 EVIDENCE: The registered manager has been in post since 2005 and demonstrates a full commitment to the home and it’s residents. He is a qualified Registered Nurse for Mentally Handicapped and Learning Disabilities and holds relevant management qualifications. He currently is only allocated two shifts a week for his management duties, working the rest of the time with the residents as either carer or driver. Although he is dedicated to his role, it is evident he needs more time to fulfil the management role completely and the organisation is strongly advised to look at current staffing levels to ensure sufficient management time is allowed. The frequency of staff meetings, formal and informal supervision was indicative of an open and supportive atmosphere. Regulations 26 (Monthly visits by the proprietor) are undertaken and evidence was seen of their completion. Relevant policies and procedures for the safety and welfare of the service users are in place. The manager has introduced systems to demonstrate these had been communicated to staff with evidence of staff signing that they have received the policies. In addition any additional information of relevance to residents had been shared with them. The management of Health and Safety in the home protects the residents and staff with all required maintenance and recording completed. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 X 5 3 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 2 25 2 26 X 27 2 28 X 29 1 30 3 STAFFING Standard No Score 31 3 32 2 33 2 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 3 X 3 X Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 24 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 13, 16 & 23, Requirement The manager must ensure that the communal rooms are appropriately and effectively furnished, they should be designed to meet the specific needs of the service users. This requirement has been carried over form the last report. The numbers of staff must ensure the needs of the service users can be met. The registered person must provide service users with toilet and bathroom facilities, which meet their assessed needs and offer sufficient personal privacy. In that the proposed new bath is provided. The registered manager must carry out an assessment on the bedroom without a sink to ensure the current service user has full access to washing facilities and their personal hygiene needs are met. The assessment is to be forwarded to the Commission. Timescale for action 31/01/08 2. 3. YA33 YA27 18(1)(a) 23(2)(j) 31/03/08 31/03/08 4. YA26 23(1)(b) 31/12/07 Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA37 YA1 Good Practice Recommendations It is recommended that more management hours are provided It is recommended that the updated statement of purpose includes all the information required by Schedule One of the Care Standards Act 2001. Willows (The) DS0000013832.V349738.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email:inspection.southeast@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) DS0000013832.V349738.R01.S.doc Version 5.2 Page 27 - 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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