Care Home: Willow House

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What the care home does well People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People`s health, personal and social care needs are met by the service. The home has a plan of care that the person, or someone close to them, has been involved in making. If people take medicine, they can manage it themselves if they are able to do, but they are unable to do so, the care home supports them with it, in a safe way. People`s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. Each person is treated as an individual and the care home is responsive to people`s interests and social needs. People living at the home are part of their local community, and the staff at the home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. People have nutritious and attractive meals and snacks, at a time and place to suit them. If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People stay in a home that has is clean, and enough space and facilities for them to lead the life they choose and to meet their needs.The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their rooms feel like their own, it is comfortable and they feel safe when they use it. People have safe and appropriate support as there are enough competent staff on duty at all times. They can have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. People`s needs are met and they are cared for by staff that get the relevant training and support from their managers. People get the right support from the care home because the manager runs it appropriately with an open approach that makes people feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. After looking at the information contained within the individual records held at the home, and after considering the feedback from people living at Willow House, it is clear that approach and systems that are in place are consistent and reliable, and operated by a competent management and staff team. What has improved since the last inspection? At the last inspection in May 2007, a requirement was made that the staff must consult with individuals or their representative about the development of care plans. This has been done. The Commission also asked the staff to ensure that the plans showed how individual needs, in relation to their health and welfare would be met by the home. This has been done. The care plans that were looked at contained very good levels of information to show that the staff at the home had taken account of the needs and desires of individuals living at the home, and the plans were seen to set out in detail the actions staff needed to take to meet people`s needs in an individualized fashion. CARE HOMES FOR OLDER PEOPLE Willow House 396 Halifax Road Hightown Liversedge WF15 6NG Lead Inspector Tony Brindle Unannounced Inspection 18th July 2008 10:30 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 Willow House DS0000026298.V368896.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. Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willow House Address 396 Halifax Road Hightown Liversedge WF15 6NG 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) 01274 872624 01274 864996 willowhouse@tesco.net Mr Ronald Sykes Mrs Susan Morgan, Mrs Barbara Sykes, Mrs Julia McDermott Mrs Susan Morgan Mrs Julia McDermott Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st May 2007 Brief Description of the Service: Willow House is a privately family run residential home and is located in the Hightown area of Liversedge. The home provides accommodation for up to twenty-eight ladies. It is a detached property and has had several extensions and adaptations in order to make it more accessible to the service users living there. A passenger lift links the ground and first floor accommodation. The home has two lounges and a large conservatory where service users are able to spend time with each other, watch television and participate in various activities and welcome friends and relatives. In addition there is a spacious, accessible and landscaped garden for service users in the warmer weather. Willow House has twenty-six single bedrooms and one double room; fifteen rooms have en-suite facilities. The bedroom accommodation is arranged over two floors. The home has four bathrooms; toilets are located on the ground floor adjacent to the lounge and dining areas. The home is situated on the main Halifax to Dewsbury road and is on a main bus route. The Provider informed the Commission for Social Care Inspection on the 12.4.07 that the fees range from £339.69 to £385.00 per week. There are additional charges for Hairdressing, newspapers, magazines, taxis and toiletries. Information about the home and the services provided are available from the home in the statement of purpose and service user’s guide. Willow House DS0000026298.V368896.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 three (3) stars. This means the people who use this service experience excellent quality outcomes. This unannounced visit started, it was a very positive and enjoyable visit. There was the opportunity to speak to people living at the home and the care staff. The care plan files of people living at the home were seen and included assessments, care plans, daily and medical records and the record of activities. Staff records were also seen and included application forms, references, police checks and training records. A sample of people’s medications and monies were checked and a look around the home was undertaken. Other information considered was the home’s returned Annual Quality Assurance document. The inspector would like to take the opportunity to thank the staff and people living at the home for their hospitality, patience and co-operation throughout the visit. What the service does well: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People’s health, personal and social care needs are met by the service. The home has a plan of care that the person, or someone close to them, has been involved in making. If people take medicine, they can manage it themselves if they are able to do, but they are unable to do so, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. Each person is treated as an individual and the care home is responsive to people’s interests and social needs. People living at the home are part of their local community, and the staff at the home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. People have nutritious and attractive meals and snacks, at a time and place to suit them. If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People stay in a home that has is clean, and enough space and facilities for them to lead the life they choose and to meet their needs. Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 6 The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their rooms feel like their own, it is comfortable and they feel safe when they use it. People have safe and appropriate support as there are enough competent staff on duty at all times. They can have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. People’s needs are met and they are cared for by staff that get the relevant training and support from their managers. People get the right support from the care home because the manager runs it appropriately with an open approach that makes people feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. After looking at the information contained within the individual records held at the home, and after considering the feedback from people living at Willow House, it is clear that approach and systems that are in place are consistent and reliable, and operated by a competent management and staff team. 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. Willow House DS0000026298.V368896.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 Willow House DS0000026298.V368896.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): 1, 2, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. In order to ensure the service does not operate in a potentially discriminatory fashion, the owner needs to seek advice about providing services to just an all female group. EVIDENCE: The manager explained that prior to moving into the home, people receive a full assessment of their needs by the service, to find out all their healthcare and social needs, adding that this id done to ensure that those needs can be met by the staff at the home. If a person’s needs cannot be met by the service, the manager explained that this communicated to the person either face to face or in a letter. Staff at the home said that people who are interested in moving into the home are welcome to come and visit, spend time Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 9 in the home, have a meal or even stay overnight so that they can get a feel of the place and see if it is right for them. One person living at the home said that they had visited the home before moving in and thought that being able to visit before moving in was a good idea. The manager explained that the service does not provide intermediate care. A discussion took place with the owner of the service and manager regarding their admissions policy. This came about as a result of a comment made by the owner regarding the home being an “all female service”. The discussions centred on the fact that historically, the home had catered for just women, and the owner added that the existing group of people living at the home had expressed a desire to keep it that way. It was explained that this could be seen to be discriminatory, and the owner was advised to seek advice about this issue in order to ensure that he operates the service in a non-discriminatory fashion. Willow House DS0000026298.V368896.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 & 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are met by the service. The home has a plan of care that the person, or someone close to them, has been involved in making. If people take medicine, they can manage it themselves if they are able to do, but they are unable to do so, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. EVIDENCE: At the last inspection in May 2007, a requirement was made that the staff must consult with individuals or their representative about the development of care plans. This has been done. The Commission also asked the staff to ensure that the plans showed how individual needs, in relation to their health and welfare would be met by the home. This has been done. The care plans that were looked at contained very good levels of information to show that the staff at the home had taken account of the needs and desires of individuals living at the home, and the plans were seen to set out in detail the actions staff needed Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 11 to take to meet people’s needs in an individualized fashion. The manager explained that people living at the home could expect that their personal plan to change as their needs for support and care change. This was evidenced within one plan that showed how it had been revised taking into account a person’s change in healthcare needs. One person living at the home said, “The staff write down in a plan, the details of how you need to be looked after. And what they do is, they ask you how they should do things, so that they know, what they are doing is acceptable and how you want it”. The plans were found to be available to people living at the home, and where a risk had been identified the appropriate risk assessments had been completed. Assessments such as those relating to nutrition, tissue viability and where there is a risk of falls were found on file. The manager said that for her and the staff an important aspect of what they do at the home is trying to keep people healthy or help them to regain health if they have been ill. The records show that this is not only done by ensuring that people have access to the right healthcare support systems within the community, but by the work the staff do through monitoring people’s health, weight, fluid and dietary intake, and very importantly their general well-being. The manager explained that people’s medicines are organized by the home for them, and as a result the staff have undergone training in this area, so that they are knowledgeable about what kinds of medication are being used, why they are being used and their effects. Information contained with the training records showed that staff have had relevant training. A check of the medication systems found everything to be in good order, and the staff that were spoken to about the system medication were found to have a good understanding of the systems and procedures in place that ensure that people get the right medication at the right time, thus promoting their health and ensuring their safety. Observations on the day found that the staff respect and actively promote people’s privacy and dignity, with the staff talking to people in respectful ways, and responding to their requests in a positive and timely fashion. The records show that meetings with the people living at the home and their relatives are held on a regular basis, and one person living at the home said that this gives people the opportunity to make comments or raise concerns about the quality of the service they experience. The manager said that this gives people the chance to contributing to, and influence how the home is run and how the services are to be delivered. After looking at the information contained within the individual records held at the home, and after considering the feedback from people living at Willow House, it is clear that approach and systems relating to health and personal care are consistent and reliable, and operated by a competent staff team. Willow House DS0000026298.V368896.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 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Each person is treated as an individual and the care home is responsive to people’s interests and social needs. People living at the home are part of their local community, and the staff at the home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. People have nutritious and attractive meals and snacks, at a time and place to suit them. EVIDENCE: Discussion with some of the staff showed that they are aware of the need to plan the routines and activities of the home in a way that meets the choice and wishes of the people living there. Observation of care practices, and the way people are supported shows that the staff are flexible and attempts to provide a service, which is as individual. People living in the home say that are spoken with as to how they would like to spend their time, and how they would like to be cared for. Staff who were spoken with said that a number of activities are provided for people to get involved with. A record of these activities was looked at and was found to offer a variety of activities based on the needs and interests of people living at the home. One person who was spoken with Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 13 explained that they really enjoyed the activities and said that they like the variety on offer. The manager explained that the home has open visiting arrangements and one person said that they could entertain their family/or friends in their own room if they wanted instead on staying in a communal area. The manager explained that unless there are legal reasons for people not to do so, they could continue to carry out their own financial, legal and other personal business. She added that people can decide who should know about, and have access to, their personal business. The records show that people can keep and control their money and their personal belongings, unless their individual circumstances mean that specific legal arrangements have been made. A check of the records and money held by the manager found no discrepancies. It is clear from visiting people’s bedrooms, that people are able to have personal possessions in their room. People at the home said that the food in the home is of an excellent quality, well presented and meets their dietary needs. A look at the menus confirmed that the home offers a wide range of choice of meals, which in some ways could be described as like that offered by a restaurant. A sample of the meal on offer on the day of the visit found the food to be nicely presented and of a high standard in taste, texture and flavour. After looking at the information contained within the individual records held at the home, and after considering the feedback from people living at Willow House, it is clear that approach and systems relating daily activities and social interests are consistent and reliable, and operated by a competent staff team. Willow House DS0000026298.V368896.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. EVIDENCE: The records show that the service has a complaints procedure, which is available within the home. 3 people were spoken with who all said that they understood how to make a complaint and who to go to. The records show that when complaints are received by the manager, they are recorded properly, and the right people are notified and spoken to, at the right time. The policies and procedures regarding the safeguarding of people were found to be satisfactory. Within the policy there is clear information as to when incidents need external input and who to refer the incident to. Discussion with 2 staff members showed that they had an awareness of the content of the policy and would know what immediate action to take and when and who to refer any incident on to. A group of people living at the home said that they feel safe. The training records show that the staff team have received area of safeguarding vulnerable adults from abuse. Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 15 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 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People stay in a home that has is clean, and enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their rooms feel like their own, it is comfortable and they feel safe when they use it. EVIDENCE: Observations of the home found that building has a well-maintained environment, which provides aids and equipment to meet the care needs of the people living at the home. It was noted that the shared areas provide a choice of communal space with opportunities to meet relatives and friends in privacy or in their own rooms. Two people living at the home said that there is a choice of bathing facilities, both assisted and unassisted, showers and baths and there are a number of toilets strategically placed around the home. The Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 16 records show that the management has a good infection control policy, and observations made on the day found this policy being put into practice. The owner of the home explained that there are plans to extend the home, and that these plans have been seen by the relevant agencies such as building control, the fire officer and the CSCI. After looking at the information contained within the individual records held at the home, and after considering the feedback from people living at Willow House, it is clear that approach and systems relating to the environment and food offered to people, are consistent and reliable, and operated by a competent staff team. Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 17 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 &30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People have safe and appropriate support as there are enough competent staff on duty at all times. They can have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. People’s needs are met and they are cared for by staff that get the relevant training and support from their managers. EVIDENCE: The manager said that because people’s needs may change over time and because every person living in the care home will have their own changing needs, she makes sure that that the management and staffing arrangements are always sufficient to meet those needs. The rotas confirmed that there were sufficient people in duty on the day of the visit, and also showed that changes are made to meet people’s needs on a day-to-day basis. Discussion with people living at the home shows that they have confidence in the staff that care for them. One person said that the staff were very good and very caring. Another said that the staff were like their family, and another said that they couldn’t go on without the staff. The records show that the service clearly defines the roles and responsibilities of staff through accurate job descriptions and specifications. The records show Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 18 that a good level of training is offered to the staff team. The records show that two written references are obtained before appointing a member of staff, and any gaps in employment records are explored. The registered manager said that new staff are confirmed in post only following completion of a satisfactory CRB check, and satisfactory check of the Protection of Vulnerable Adults and NMC registers (where appropriate). The records confirmed this. After looking at the information contained within the individual records held at the home, and after considering the feedback from people living at Willow House, it is clear that approach and systems relating to the staff are consistent and reliable, and operated by a competent management team. Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 19 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 & 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People get the right support from the care home because the manager runs it appropriately with an open approach that makes people feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. EVIDENCE: Information contained within the records show that the managers and staff make sure that so far as is reasonably practicable, the health, safety and welfare of service users and staff is promoted. The records show that this is done by way of staff training, fire safety system testing, risk assessment and Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 20 safety system monitoring. Staff explained that they take part in fire drills, and have received fire safety training, along with health and safety training. The records supported this. The records show that the home has satisfactory insurance cover, with certificates on display. The systems relating to the safekeeping of people’s monies and valuables were found to be in good order. The staff said that they receive formal supervision, and the records confirmed this. The company has developed a quality assurance scheme. This involves obtaining feedback from service users, their families and professionals. Once feedback is received, than a report on the quality of care will be published with an accompanying action plan (if required). The records show that monthly management visits take place on behalf of the service provider. After looking at the information contained within the individual records held at the home, and after considering the feedback from people living at Willow House, it is clear that approach and systems relating to the staff are consistent and reliable, and operated by a competent management team. Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 21 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 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 4 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 4 X X 4 Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 OP2 OP3 Good Practice Recommendations In order to ensure the service does not operate in a potentially discriminatory fashion, the owner needs to seek advice and clarification about providing services to just an all female group. Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 23 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 Willow House DS0000026298.V368896.R01.S.doc Version 5.2 Page 24 - 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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