Care Home: The Willows Barton

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What the care home does well The home had a staff team that knew the people who lived in the home well. A core group had worked at the home for many years and there was a low staff turnover. Staff received a variety of training to help them meet people`s needs and were supervised on a regular basis. People spoken to were complimentary about the staff stating they were well looked. Care was provided in a way that respected privacy. The home provided lots of activities for people and staff and relatives helped in fundraising for trips out and entertainments. People who lived in the home were involved in all aspects of running the home through questionnaires and meetings and their opinions were valued. People generally liked the meals provided and there was a choice at all mealtimes although staff were not always proactive in ensuring people were offered these. The home was well managed and provided a clean and safe environment for people and the atmosphere was relaxed. The services provided by the home were monitored well and results of any surveys were displayed for all to see. What has improved since the last inspection? The home had looked at the range of activities on offer for people with sight and hearing difficulties as some people could miss out on things. Equipment had been purchased and the activities coordinator gave one to one time. The recruitment checks now included most of the checks required but more care must be taken in obtaining two references. What the care home could do better: There were some issues highlighted in surveys, discussions with staff, and during the examination of information on the day that must be improved. The home completed assessments and wrote care plans to meet identified needs but these were not consistently applied particularly around social care needs. Evaluation of the care provided was not sufficiently detailed to ensure that people`s health needs were continuously monitored. The homes recruitment processes must be addressed as reference checks had not been completed and this could place service users at risk. CARE HOMES FOR OLDER PEOPLE The Willows Barton Willow Drive Barton On Humber North Lincolnshire DN18 5HR Lead Inspector Mrs Kate Emmerson Key Unannounced Inspection 11th March 2008 09:30a 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 The Willows Barton DS0000002880.V361976.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. The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Willows Barton Address Willow Drive Barton On Humber North Lincolnshire DN18 5HR 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) 01652 632110 Barton Medical Services Limited Mrs Susan Brumpton Care Home 39 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (39) of places The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE(E) The maximum number of service users who can be accommodated is: 39 12th December 2006 2. Date of last inspection Brief Description of the Service: The Willows care home is situated in a quiet cul-de-sac close to the centre of Barton on Humber. The town is well serviced by local transport and has a variety of shops, pubs and restaurants. The Willows is a single storey building divided into five units, each having two toilets and either a bathroom or shower room. The bedrooms are all for single occupancy. The home has three lounges and a separate dining room with individual tables and chairs set out. From the main corridors service users can access three secure patio areas, which have water features and garden furniture. An enclosed lawned area is accessible from unit five. All areas of the home are accessible to wheelchair users. According to information received from the home on 29.08.06 their weekly fees are £352 to £415.66. There is also a £29.80 top up for people funded by Social Services. Items not included in the fee are toiletries, hairdressing, chiropody, newspapers and transport for various activities. The homes statement of purpose and service user guide was on display in the home and available to prospective service users. The Willows Barton DS0000002880.V361976.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 2 star. This means that the people who use this service experience good quality outcomes. The visit was unannounced and took place over one day in March 2008. Throughout the day we spoke to people who lived in the home to gain a picture of what life was like for people who lived at The Willows. We also had discussions with the manager, care staff and catering staff. We looked at records including those relating to the care people received and those relating to staff recruitment and training. A tour of the building was conducted and a random selection of bedrooms was checked. Prior to the visit to the home the inspector had sent out a selection of surveys to service users, family members and a selection of staff members. These were checked and comments used throughout the report. What the service does well: The home had a staff team that knew the people who lived in the home well. A core group had worked at the home for many years and there was a low staff turnover. Staff received a variety of training to help them meet people’s needs and were supervised on a regular basis. People spoken to were complimentary about the staff stating they were well looked. Care was provided in a way that respected privacy. The home provided lots of activities for people and staff and relatives helped in fundraising for trips out and entertainments. People who lived in the home were involved in all aspects of running the home through questionnaires and meetings and their opinions were valued. People generally liked the meals provided and there was a choice at all mealtimes although staff were not always proactive in ensuring people were offered these. The home was well managed and provided a clean and safe environment for people and the atmosphere was relaxed. The services provided by the home were monitored well and results of any surveys were displayed for all to see. The Willows Barton DS0000002880.V361976.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. The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 7 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 The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 8 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): 3, Standard 6 is not applicable as the home does to provide intermediate care People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Assessments of peoples needs were completed before admission, these had improved and now recorded detailed information about peoples care needs. EVIDENCE: The home evidenced that service users were only admitted after an assessment of need had been carried out by the manager and by care management when funded by them. On the whole the home had obtained copies of care management assessments. The assessments enabled the management to make a decision as to whether the persons’ needs could be met in the home. The assessments were used to formulate care plans to meet peoples needs. The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 9 There was evidence that the assessment process continued after admission and assessments and care plans had been updated as further information about people’s needs and preferences was gathered. The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 10 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. This judgement has been made using available evidence including a visit to this service. Generally the home maintained people’s health and personal care but a lack of detailed evaluation of the care provided means that health problems may not be identified and addressed in a timely manner. People were, if appropriate, enabled to self medicate if they wished and medication policies and procedures were adequate. People felt they were treated with respect and felt their privacy was up held EVIDENCE: Four care files were examined and the home evidenced that a lot of information was gathered during the first few days of admission. For example personal profiles with a social history and likes and dislikes were completed. Risk assessments were completed for nutrition, falls, moving and handling, bed The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 11 rails and the use of the hoist. An inventory of possessions was made and an assessment as to whether people were able to self-medicate. Overall the care plans were detailed and had been kept up to date as needs had changed. Care plans had been evaluated on a monthly basis but this process did not always include an evaluation of all events over the previous month. In one case where it was recorded in diary sheets that a person had had problems with their swallowing this had not been identified in evaluation to check if this was still an ongoing problem and the care plan updated. Monitoring records such as weight charts were not always taken into account and in one case where one person had had a significant weight loss this had not been identified in evaluation. A lack of detailed evaluation means that health problems may not be identified and addressed in a timely manner. Daily records describing the care people had received were completed in detail. However there was some use of inappropriate statements such as describing a person as ‘buzzer happy’ or ‘been very difficult today’. This questions the staff skill base and attitude towards people who may display more challenging behaviour. The manager was advised to audit diary records to identify staff that may require further training in this area. There was evidence that people had access to health professionals and services such as opticians, chiropodists and dentists. Records were maintained of visits. Medication was generally well managed. Records of receipt, administration and disposal were maintained. Medication was stored appropriately and staff members were observed to check people took medication on administration. Risk assessments had been completed for people to self medicate and records were maintained of staff checks and support where people were selfmedicating. Where medications had been changed there were no records to support the changes. For example discussions with the GP were not recorded and the changes to records had not been signed and witnessed as correct. Hand transcribed records, for example where a person had been admitted for respite or printed administration records were not available, had not been signed by the person making the record and had not been witnessed as checked and correct. This is recommended to ensure safe practise and to minimise the risk of errors. People who lived in the home said staff were polite and respectful at all times. They described how staff ensured that their privacy was maintained when they were assisting with personal care tasks. This was confirmed by observing staff when they were assisting people. The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 12 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. This judgement has been made using available evidence including a visit to this service. The home provided flexible routines, which enabled people to make choices about all aspects of their lives. Promotion of individual choices in meals and activities could be improved. EVIDENCE: The home employed an activity coordinator for two hours a day during the week and two other staff had two hours per week each especially for provision of social stimulation. In all the hours provided for social stimulation amounted to fourteen hours per week. There was evidence of visiting entertainers, trips out to local facilities and activities provided within the home. The home had recently purchased a game machine to enable people to take part in activities from their chair. People who were unable to join in the main activities due to health problems or sensory deficits were provided with one to one time with the activities coordinator and systems such as headphones for the TV and talking books The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 13 were made available. One person said that the library in the home was very good. There was some evidence that people’s needs in this area were assessed and care plans developed but this hadn’t been consistently applied in the files examined. There were some efforts to record the activities that people had participated in but again this was inconsistent. People who lived in the home expressed differing views on the activities available to them. One said that the activities available were ‘not of interest’; another said that the activities were ‘good’ and another said there was ‘lots to do’. This highlights the inconsistency of individual planning. There was evidence that people made choices about aspects of their lives for example, management of their finances, choosing the colour scheme of their bedroom and communal areas, personalising their bedrooms, the routines in the home and activities they wished to participate in. There was evidence that suggestions made were listened to for example on what to spend the comfort fund, activities and menu changes. Routines were flexible with no set times for rising, retiring and visitors. People spoken to were generally happy with the meals provided. Comments included ‘the meals are nice’, meals are excellent and ‘the food is reasonable but the meat is poor quality’. One of the main issues regarding the food was the perceived lack of choice. Although the menu clearly showed that there were alternatives to the main menu and kitchen records evidenced that people had choices people, still felt that here was little choice available. Comments included ‘fed up with sandwiches’, not enough choice’ and ‘no choices are offered’. The procedures for ensuring people know what choices were available to them was not sufficiently robust especially for those who did not come to the dining room for meals. This needs to be reviewed. Good efforts had been made to ensure that the dining room was a pleasant area, it was well decorated and the tables had fresh tablecloths and napkins. An individual low table provided for a person in a wheelchair was also laid with a tablecloth and napkin. Lunch was unhurried and staff members were observed serving lunch in a friendly way. People were enabled to be as independent as possible with the use of aids and prompts by staff. The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 14 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. This judgement has been made using available evidence including a visit to this service. Service users are able to complain about services and are protected from abuse by the general openness within the home, staff members’ knowledge of policies and procedures and adult protection training. EVIDENCE: The home had a complaints procedure displayed in the home and staff members were aware of the procedure and the documentation used to record niggles, concerns or more formal complaints. People spoken to knew who to speak to if they had any complaints and some named the manager in person. During the course of the inspection it was clear that people felt able to express openly their thoughts on the care and services they received. Four complaints had been received by the home since the last inspection although there were only records for two investigations on file. The manager was requested to send a summary of the complaints and any action taken to the Commission. Information received from the home prior to the inspection and from the discussion with the manager indicated that the home had policies and procedures to cover adult protection and prevention of abuse, whistle blowing, The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 15 aggression, physical intervention and restraint and management of resident’s money and financial affairs. The staff on duty displayed a good understanding of the safeguarding procedures and were confident they would report any issues. All staff had completed training in the protection of vulnerable adults from abuse. The manager had received training around referral to the local authority and their investigation procedures. A referral made to the Safeguarding Team regarding the care a service user received after a fall out of bed at the last inspection had been investigated and was unfounded. Some action had been taken in response to the recommendations made from this investigation. For example improved first aid training had been provided to all senior staff. The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 16 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, 25 and 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. On the whole the home provided a clean and comfortable environment for people however there were some environmental issues that needed to be addressed as they put peoples safety at risk. EVIDENCE: The home had three lounges and a large dining room and each was furnished to a reasonably good standard, and although the decoration in some areas of the home was looking a little jaded it generally had a homely appearance. The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 17 The home had three courtyards, which were accessible to all the service users and had water features; a barbeque and raised flowerbeds so service users could join in gardening activities if they wished. Individual bedroom doors had privacy locks and people spoken to confirmed they could bring in items of furniture to personalise their rooms. This was evidenced to varying degrees during a tour of the home. People told the inspector the home was always nice and warm, the staff cleaned it well, they were happy with their personal laundry. People were free to choose any area of the home to sit in. Those spoken to were happy with the home and their bedrooms. There was evidence of ongoing redecoration as rooms became vacant although as the handyman was completing this amongst other tasks it will take sometime to complete. A wet room had been completed to add to the options available in the home for people to bathe/shower. During the tour of the building it was observed that one person had their bedroom door wedged open. They confirmed that this was their choice and that the door was wedged open during the night also. This is unsafe practice and puts people at increased risk in the event of a fire. The manager was advised to liaise with the fire officer and discuss alternative and safer ways of holding the door open. The hot water temperature in one bathroom was recorded at 45°C. This puts people at potential risk of accidental burns and hot water temperatures must be kept close to and not exceeding 43°C. This was reported to the manager who stated that the handyman would adjust this immediately. There were some window handles broken in bedrooms, which meant that the windows could not be opened and some of the enamel in sinks in the bedrooms was very worn and unsightly. The manager was aware of these issues and stated that new window handles had been ordered. Two bedrooms were odorous and one sluice area was dirty otherwise the home was very clean and tidy. The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 18 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. This judgement has been made using available evidence including a visit to this service. The home had sufficient numbers of care staff in the home to meet people’s needs. A good staff training and induction programme ensured that well-informed carers supported people. There was improvement the recruitment of new staff but one reference check had not been obtained and this could place people at risk. EVIDENCE: Staff rotas were examined and discussions with staff indicated that the home had sufficient staff members in place in terms of numbers. People who lived in the home were very complimentary about the staff describing them as good or excellent. The manager stated that the numbers of staff were decided following the Residential Forum guidance. Although she had no evidence of this because she said that the operations manager completed this piece of work. The manager stated that at nights there were two waking care staff and one on call in the building, however the on call was not indicated on the staff rota. This is necessary so that a full record of staff is maintained. The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 19 The home had a training plan, which covered mandatory and service specific training. Pre inspection information and staff spoken to during the visit confirmed a good training programme. There was evidence that where a training need had been identified in supervision the manager had arranged for training in this area to be given promptly. Induction was allied to skills for care standards and senior staff signed off the competence of new staff. The home provided information that more than 50 of care staff were trained to NVQ level 2 or 3 and more staff were progressing through the course. Four recruitment files of new staff members were examined. The files did not contain the required photos of staff. Application forms were in place and the required two references had been obtained for three of the staff. A fourth staff member only had only one reference. The files contained all other safety checks required including Criminal Record Bureau checks. The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 20 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 good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager provided leadership and guidance to staff and ensured the environment was generally a safe place to live and work. EVIDENCE: The manager had completed her Registered Managers Award. The home was well managed and staff indicated that they received support and guidance from the manager. Records and discussions with staff members indicated that the home was on track for staff to receive at least six supervision sessions per year. The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 21 Service users views about the home were obtained via meetings and the homes robust quality assurance processes. These consisted of audits completed by various staff members and questionnaires sent out to service users, relatives, professional visitors and staff throughout the year on a range of issues such as meals, personal care, timeliness of staff answering buzzers, laundry and cleanliness. Action plans were produced to address shortfalls and staff were informed of the results and the action required to put things right. Results of the surveys were distributed around the home. The home had achieved the Gold Standard Award for quality monitoring awarded by the local authority. The manager and proprietors produced a business service plan on an annual basis and made this available to the home and the Commission. Generally the home managed the personal allowances for service users in an appropriate way. Individual logs were maintained for each service user and receipts obtained for purchases made on their behalf. Two signatures were obtained for all transactions. The manager was generally proactive in promoting the safety and wellbeing of the service users who lived at the home and the staff who worked there. Staff had completed health and safety training. Service records were completed and fire prevention management was in place including training, drills and equipment checks. The gas safety certificate was had expired but the engineer was in the home on the day of the inspection to address this. The manager was requested to send a copy of the certificate when this had been completed. There were some environmental issues that may put people at risk and these are detailed in standards 19 to 26. The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 22 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 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP12 Regulation 16(2)(n) Requirement The registered person must ensure that people’s social needs are consistently assessed and care plans are developed so that activities can be developed further to meet individual needs. The registered person must send to the Commission a summary of complaints received since the last inspection, which describes the content of the complaint, outcome and any action taken. Records of investigation of complaints must be held in the home. The registered person must ensure that bedroom doors are not wedged open to minimise the risk of the spread of fire. The registered person must ensure that hot water temperatures at outlets accessible to people living in the home is kept close to and not exceeding 43°C to prevent accidental burns. The registered person must ensure that the home is kept free form unpleasant odours. DS0000002880.V361976.R01.S.doc Timescale for action 01/06/08 2 OP16 22(8) 01/06/08 3 OP19 23(4) 11/03/08 4 OP25 13(4) 11/03/08 5 OP26 14(2)(k) 01/06/08 The Willows Barton Version 5.2 Page 24 6 OP29 19 7 OP38 23(2) The registered person must ensure that two references are obtained for all new staff prior to employment. (The previous timescale of 31/01/07 was not met) The registered person must send a copy of the gas safety certificate to the Commission to evidence that this work has been completed. 11/03/08 01/05/08 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 OP8 OP9 Good Practice Recommendations The registered person should ensure that care plans are evaluated in more detail to ensure that people’s health is monitored and any issues addressed in a timely manner. The registered person should ensure that changes to medication records and hand transcribed records are checked and witnessed as correct. This is recommended to ensure safe practise and to minimise the risk of errors. The activity coordinator should make monthly, ‘at a glance’ records in order to capture information when service users don’t participate in activities. This will enable staff to investigate why and tailor particular activities. The registered person should ensure that people are made aware of the choices/alternatives available at meal times. 3 OP12 4 OP15 The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 25 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 The Willows Barton DS0000002880.V361976.R01.S.doc Version 5.2 Page 26 - 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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