Care Home: Willowbrook

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What the care home does well Peoples needs are well met by a number of working practices that the home follows – A transition plan is created for prospective people so that their admission is arranged to be as non disruptive to them as it can be, there are detailed care plans in place to meet their needs, staff read care plans so they know how to meet these needs, staff were observed to have positive and encouraging relationships with people and to promote their independence and day to day choices, medication is safely delivered to people to meet their health needs, Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 staff are aware of how to protect people from abuse, complaints are properly looked into and a detailed response given so that people can be confident that action will be taken if needed, there is a strict daily monies procedure to protect peoples monies, people live in a comfortable and odour free home, there is a good general training programme for staff, and robust health and safety systems to protect peoples welfare. What has improved since the last inspection? Not applicable. This is the first inspection of the home. What the care home could do better: Peoples needs could be further improved by – Having user friendly information that people can understand, that all risk assessments are properly detailed to protect people and staff, that the number of staff to residents is clearly shown in care plans to ensure assessed needs are fully met, that previous health checks are recorded to prompt appointments for these checks, the complaints procedure needs to give people the option of contacting the Lead Agency at the first stage if they have a concern, there needs to be staff training on all peoples conditions so that staff can meet all their needs and that the home has copies of staff records so that it can be checked in detail as to their abilities and previous record. Key inspection report CARE HOME ADULTS 18-65 Willowbrook Wendy Close Leicester Leicestershire LE5 2HE Lead Inspector Keith Charlton Key Unannounced Inspection 5th October 2009 09:15 Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Willowbrook Address Wendy Close Leicester Leicestershire LE5 2HE 0114 242 9797 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) Voyagecare.com Voyage Limited Ashraf Hanie Omar Care Home 6 Category(ies) of Physical disability (6) registration, with number of places Willowbrook DS0000073183.V377335.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: 2. Physical disability - Code PD The maximum number who can be accommodated is: 6 Date of last inspection This is the first inspection of the service. Brief Description of the Service: Willowbrook is registered to provide care for six adults with physical disabilities. The home is pleasantly furnished and decorated to a high standard. There is a large garden to the rear of the property. Willowbrook is situated in a cul de sac near to an estate and there are a number of shops nearby. Residents attend a range of different activities, including local day centres and colleges. Fees currently range from £1400 to £2139 per week - this information was provided by the Manager at the inspection. The home provides information to residents and prospective residents in the form of a Statement of Purpose and Service Users Guide that describes the services it offers, available so as to give a view as to the quality of life for residents and their representatives. Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. ‘We,’ as it appears throughout the Inspection Report, refers to ‘The Care Quality Commission. The inspection process consisted of pre-planning the inspection, which included reviewing the Annual Quality Assurance Assessment (AQAA), which is selfassessment tool completed by a representative of the service, We sent surveys to people who use the service along with staff and they were all positive as to how the quality of life for people who live there is of a high standard. The unannounced site visit commenced on the 5th October 2009 and was carried out by Keith Charlton. The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was ‘case tracking’. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff at Willowbrook. Two people were selected. Discussions were held with the Manager and two members of staff. We were able to communicate directly with residents though this was limited due to their communication needs. We received surveys back from three people who live in the home and six staff. These were very positive in general about how the home met the needs of people who live in the home. We have referred to surveys in the relevant sections of this Report. What the service does well: Peoples needs are well met by a number of working practices that the home follows – A transition plan is created for prospective people so that their admission is arranged to be as non disruptive to them as it can be, there are detailed care plans in place to meet their needs, staff read care plans so they know how to meet these needs, staff were observed to have positive and encouraging relationships with people and to promote their independence and day to day choices, medication is safely delivered to people to meet their health needs, Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 6 staff are aware of how to protect people from abuse, complaints are properly looked into and a detailed response given so that people can be confident that action will be taken if needed, there is a strict daily monies procedure to protect peoples monies, people live in a comfortable and odour free home, there is a good general training programme for staff, and robust health and safety systems to protect peoples welfare. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Willowbrook DS0000073183.V377335.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 Willowbrook DS0000073183.V377335.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Willowbank have had their needs properly assessed before moving into the home so that staff can meet these needs from the beginning. EVIDENCE: The AQAA stated that there is a thorough assessment procedure that includes the person, social worker, carer etc then a transition plan is worked out to tailor to the individual needs of the person. There are visits arranged to the home and to the persons home setting. A review takes place after twelve weeks to ensure that needs are being met. We case tracked a person living in the home who had moved into Willowbank. We checked that he had received information to help him/his relatives with the choice of home, but because the person had communication problems it was not possible to check he had received this information. The Manager stated in the AQQA that a thorough assessment is done and that they were looking at providing more accessible information for residents who could not read. Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 9 We also checked that people living at the home had their needs properly assessed prior to moving to Willowbank to ensure that the staff at the home could meet their needs. We found this to be the case as the assessment covered all important issues such as reason for referral, health, speech and communication, diet, life skills etc, though did not have the dates of past health checks to prompt staff to help make these appointments and improve people health. Two people who live in the home stated in surveys that they had not received enough information about the home before they moved in. This issue needs to be looked at so this is not the case with new admissions. Willowbrook DS0000073183.V377335.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The individual needs and choices of each person living at Willowbank are well documented and acted upon by staff. EVIDENCE: I think we get cared for very well here, one person said. The AQAA stated that there are detailed care plans and risk assessments, which are reviewed with the person and that staff receive extensive training to ensure that they can meet peoples needs. We looked at the care records of two people living at Willowbank. We found very detailed plans to support the care given to people who live at the home. Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 11 There was a variety of useful information available to staff to meet peoples needs and this was well presented with peoples strengths noted first then their support needs, making short and long term goal so that people can be helped to become more independent and realise their ambitions. Plans also detailed the mental health conditions of residents and supplied detail to staff as to how to approach any challenging behavior they may meet, though the Manager was asked to supply more detail to one plan to ensure the welfare of staff and residents was fully covered. There are also a number of risk assessments so that residents can be protected from all identified risks. Staff said that they read Plans to ensure they can meet residents needs and keeping up to date with Plans is encouraged by management. We saw that care records were routinely up-dated to ensure they reflected the changing care needs of people living in the homes. During our visit we observed staff and management being very friendly to residents and explaining what they were doing to reassure residents and greeting them when they came into the dining room. There was evidence that residents are able to live their own lives, e.g. going out to places in the community, choice of meal, choice of activity, when to get up, the ability to do household chores, using the homes gym facilities, gardening etc. Willowbrook DS0000073183.V377335.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): This is what people staying in this care home experience: 12,13,15,16,17. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Willowbank have lots of opportunities to have a varied lifestyle. EVIDENCE: Yes, its free and easy here. We dont get told what to do. I can go out when I want, one person said. The AQAA stated that people are encouraged to have lifestyles based on their own choices, their likes and dislikes are recorded and acted upon and that people can go to day centres and colleges if they want. We looked at the life plans of people who live at Willowbank. These contain details of activities recorded so that these can be checked and reviewed as Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 13 needed to ensure peoples needs are met. There is also a very useful questionnaire covering a large range of hobbies and interests like what kind of films people like, whether theme parks are liked etc which helps to plan activities. Plans showed us that residents are able to experience a varied social life. People go to a day centre/college as they choose and have a variety of activities in the community to choose from. We saw two people going out with staff and the other resident working in the garden, which followed their expressed choices of what they wanted to do. We saw that staff are sensitive to the needs of people living at the homes. They were aware of the preferences of people in their daily activities. We saw staff talk to and interact well with people who live at the home. Staff also were aware of how to effectively communicate with each person. We saw lunch was provided and people living at the home having a meal of sandwiches with a choice of fillings. There was evidence of plenty of fruit/vegetables included in the menus which had sufficient variety. A good selection of fruit was observed to be readily available in the kitchen/dining room for people to help themselves to, thereby encouraging a healthy diet. Willowbrook DS0000073183.V377335.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at Willowbank receive proper support to meet their personal and healthcare needs. EVIDENCE: We looked at the personal and healthcare records of people who live at Willowbank. We saw that they have good access to healthcare services to meet their personal and healthcare needs as described in Care Plans. The Manager said that he would be producing Health Action Plans to ensure these needs are fully covered. On talking to staff and looking at the records, we found that staff act quickly on concerns they have about peoples needs, and these prompt actions have resulted in a better quality of life for those concerned. Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 15 We looked at a person being assisted by staff to eat and drink and how he was encouraged to do this himself and had appropriate aids in place to help him. We looked at medication management and found that staff are administering medication appropriately to people who live at Willowbank, with no instances where medication was not signed as given. Medication is stored safely. We saw staff records and these showed us that staff have undertaken training in the administration of medication. We were informed that only carers are given permission to administer medication to people who live in the home when they have both passed an accredited course and been assessed as being able to issue medication correctly by the management of the home and we saw evidence of this form. Willowbrook DS0000073183.V377335.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People, and the families of people who live at Willowbank, can be confident that their concerns will be noted and acted upon, and they are protected from abuse. EVIDENCE: A resident said, If anything needed doing I think the staff would sort it out. The AQAA stated that the Lead Agency protocol is followed to ensure protection is there to keep people safe from abuse, and that staff have received relevant training. We looked at the complaints procedure and the Manager said that this is to be written in a format which is more helpful for people living at Willowbank to understand. The procedure does not give the complainant the choice to go directly to the Lead Agency at the first stage if they wish, instead of the home. There is a Complaints folder and complaints from outside sources have been dealt with appropriately and professionally. Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 17 There is a card (I am worried. Please contact me) that people can use to send to Head Office to say they are not happy and someone outside the home will come and speak to them to try to resolve the problem. We saw by looking at staff training records, and by talking to staff, that they have a good understanding of safeguarding policies and procedures. Staff know what to do if they suspect that a person who lives in the home is being abused in any way. We also saw by looking at staff records, and by talking to staff that they understand how to work with challenging behaviour. We checked the financial records of two people living at the home, and found good recording of money transaction and the Manager informed us that there are money checks at each handover to ensure that people are not financially abused. Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Willowbook live in a homely, comfortable environment. EVIDENCE: People said they liked their bedrooms: We can have our rooms the way we like, one person said. We looked at the communal areas of the homes and some of the bedrooms of people who live there. We found the communal areas to be brightly decorated and homely. The bedrooms were decorated to reflect the personalities and preferences of the people using them. The AQAA told us that residents choose how they like their bedrooms to be by choosing the decor etc. The Manager talked about how maintenance is followed up and said that he was trying to improve the response time to follow up routine maintenance work, though Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 19 there was no problem with getting swift maintenance if serious issues were identified. There was a stiff lock and tap in a toilet that needed freeing so that people could use it properly. The Manager said this would be followed up. The garden to the rear is partly paved and looked in a kept condition, with garden furniture there so that residents could use it. The home has its own gym and a resident said he often used it. The Manager might like to consider installing a snoozelum and a sensory garden to provide relaxation and stimulation for residents. A person asked for a swing and slide in a Residents Meeting - the Manager said this is being looked into. We saw that the home was kept in a clean, odour free condition and that staff were observed to follow infection control procedures. Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home have satisfactory staffing levels and support from a motivated and trained staff team. EVIDENCE: People said that staff were friendly and helpful towards them: Staff are good and help us when we need them, one person said. The AQAA stated that there was a detailed induction and training programme and staff were encouraged to complete their NVQ training, that more specialist training was to be arranged and the Company was looking into how people who use the service could be involved in the staff recruitment process so they can help to choose the staff that provide care for them. The staff rota indicated that when residents were in the home, there was a minimum of two and often three care staff on duty, plus the Manager five days Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 21 a week, then an awake staff member and sleep in at night with an on call system. There was one comment in staff surveys that there is not enough staff. The Manager thought that staffing levels currently met peoples needs even though two people have high dependency needs. He agreed to look at care plans to identify who needed how many staff with them at particular times as in one care plan it was not stated for a person that he needed one staff when he went out locally, but two staff when he went out of the locality, as staff had informed us. We talked to staff and saw them supporting people who live in the home. We saw good interaction between staff and people who live in the home, and staff demonstrated a good understanding of the needs of people living there. Staff said they were supported well to do their job by management, and there is detailed induction training and on going training relating to the job they do, with regular supervision, which we found to be the case in staff records. We looked at a sample of staff records, and saw that all the necessary checks were made to safeguard people who live at the home. Although there is an agreement between the Company and Care Commission it is recommended that copies of detailed checks are in place so they can be checked at the service rather that at the Head Office in Sheffield. We looked at training records and this confirmed that staff have undertaken relevant training to help them in their roles. Training included health and safety, medication management, infection control, fire, food hygiene, moving and handling, challenging behaviour training etc though training on all peoples conditions was not fully in place, e.g. for depression, arthritis, obsessive compulsive behavior etc. The Manager said that he would include this in the homes training programme. Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Detailed Health and safety systems are in place to protect peoples welfare. EVIDENCE: Yes, the home is well run, one person said. The Registered Manager, Ashraf Omar, has NVQ4 in Management and Registered Managers Award Qualifications, which we saw evidence of. Ashraf was praised by staff for his efficient and effective, supportive leadership. Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 23 There are quality assurance and monitoring systems in place, and we saw the questionnaires that go out to relevant parties to ascertain peoples views of the service so that improvements can be made if needed. The Manager said this system was to be further developed to include the views of people who live in the home. There are good systems in place to support staff - staff supervision is regular and detailed, and staff meetings are frequent and include how to improve practice. We checked some residents monies records, which were found to be detailed and in order with a daily checking system in place. The AQAA informed us of the policies and procedures the service works to, to ensure good health and safety practice in the home. The temperatures of water is regularly checked to ensure residents are protected from scalding water. One entry is to be followed up by the Manager as it was over the National Standard. Risk assessments are in place for safe working practices and fire risks were seen to be covered by regular testing and a fire risk assessment being in place. The staff we spoke to were aware of how to properly follow the fire evacuation procedure. Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 24 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 x 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 4 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 4 x 4 X 3 X X 3 X Version 5.2 Page 25 Willowbrook DS0000073183.V377335.R01.S.doc Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Willowbrook DS0000073183.V377335.R01.S.doc Version 5.2 Page 26 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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