Inspection on 18/04/07 for Windermere Rest Home

This inspection was carried out on 18th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Windermere Rest Home 09/04/09

Windermere Rest Home 09/04/08

Windermere Rest Home 05/10/06

Windermere Rest Home 13/12/05

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Windermere Rest Home 23/25 Windermere Road Southend-on-Sea Essex SS1 2RF Lead Inspector Key Unannounced Inspection 18th April 2007 10:00 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 Windermere Rest Home DS0000065465.V336966.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. Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windermere Rest Home Address 23/25 Windermere Road Southend-on-Sea Essex SS1 2RF 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) 01702 303647 Mr Kumarasingham Dharmasingham & Mrs Mithila Dharmasingham Manager post vacant Care Home 10 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (10) of places Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2006 Brief Description of the Service: Windermere Rest Home is a small, privately owned residential home providing accommodation and care for ten people who may have dementia. Accommodation consists of ten single bedrooms, a communal lounge/dining room, kitchen, two bathrooms, laundry and office. Each bedroom has a call bell facility and a TV point. A shaft lift is available to provide access to both floors. There is a small, enclosed garden to the rear of the home. The home is situated in a residential area of Southend on sea within easy access of the seafront, train links, bus services and local shops. The home provides display permits to allow visitors to use a private car park opposite the home. The home has an updated Statement of Purpose, Service User Guide and a copy of the last inspection report in the hall opposite the office. The current scale of charges as at September 2006 is between £ 369.32£430.99 per week. Some rooms carry a supplement of £8 per day. Extras charged are for hairdressing, chiropody and newspapers. Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 18th April 2007 at 10.00am. The inspection lasted 7 hours. The inspection process included • Telephone discussions with the proprietor, relatives of the people who live at Windermere Rest Home and some external stakeholders; • Face to face discussion with the newly appointed acting manager, care workers, a consultant secured by the proprietor to assist with the development of the service and people who live at the home; • Responses to a postal survey of relatives and healthcare professionals; • Examination of a sample of staff and service users’ records, supporting documentation and other records required to be kept in the home; • Direct and indirect observation. • Assessment of the improvement plan submitted to the commission in response to the previous inspection of this service. This report has been written using accumulated evidence gathered prior to and during the inspection. 24 of the 38 National Minimum Standards for Older People and the intended outcomes of these were assessed during this inspection process 8 Standards were judged to be things the home does well for residents. 14 Standards were judged to be the things that need a little improvement. 2 Standards were judged to be the things that the home needs to improve greatly to keep the residents safe and make their lives happier. What the service does well: What has improved since the last inspection? Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 6 Each person living at the home has a care plan that details how their individual care and support is to be provided in order to meet their specific health, social and spiritual needs. This plan has been further developed since the previous inspection and may be considered as ‘work in progress’. A complaints record has been developed so that it is possible to identify areas of concern within the home. Procedures relating to the safeguarding of vulnerable adults have been developed and made known to the staff team. Water temperatures are now regularly checked to ensure residents are safe from scalds. All of the important information was on staff files to make sure they are the right person for the job they are doing and to be sure they are safe to be supporting vulnerable people. A person has been appointed to manage the home. What they could do better: Care plans weren’t being used as effective working documents to ensure that the care, support and risk management strategies were specific to individuals and kept under regular review. The programme of refurbishment of the home needs to continue in order to improve the environment for the people living there. There weren’t enough staff on duty to meet the social and spiritual needs of the residents as well as their health and personal needs. The quality assessment processes at the home needs to be developed further to help to drive the quality of the service provision forward for the benefit of the people living there. The people living at the home were not supported to explore activities and pastimes for recreation and should be provided with meaningful activities to stimulate their daily life both inside and outside the home according to their personal wishes. The people living at Windermere rest Home were not offered a choice of menu daily nor were they able to access drinks and snacks themselves according to their abilities and supported by the risk management framework. Residents were not able to access all areas of their home freely. Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 7 The home did not have a training plan to ensure that the staff team had the necessary updated skills to promote and protect the health, safety and welfare of the people living at Windermere Rest Home. 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. Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 8 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 Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 9 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, 4 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service had the right policies and procedures in place with regard to the admission of new people to the home. EVIDENCE: The service has developed a Statement of Purpose, setting out the aims and objectives of the home, and a service user guide which provides basic information about the service and specialist care the home offers. This document is made available to individuals in a standard format. It was reported that the most recent Commission for Social Care Inspection report was “continually being replaced by the 2005 report and kept disappearing so that visitors did not have access to it “. On the day of the inspection visit the most recent report was present in the hallway by the manager’s office. There have been no new residents admitted to the home since the previous inspection where the home’s admissions policy and procedure was assessed as being appropriate. The acting manager described the processes that would be undertaken in the case of a new admission ensuring that any prospective resident would have the information they needed to make an informed Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 10 decision and that they would be assured that the home would meet their assessed needs. The home does not offer intermediate care. Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 11 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Routines at the home were task based on the staff teams accumulated knowledge of the residents and not led by the individual needs and wishes of the people living there. EVIDENCE: The registered provider had secured the services of a consultant to assist in achieving compliance with the Care Homes Regulations. The previous inspection identified that the care plans contained only basic information and that staff confirmed that they were not effective working documents. Care plans had been developed since then to include records of weights, nutritional assessments and risk assessments for individuals, however lacked specific detail of how the residents were to be cared for. Monthly care plan reviews had been planned and there was evidence to confirm that some had taken place. It was reported that relatives were to be invited to care plan reviews, evidence was available on one care plan sampled to confirm that a relative had been involved however there was no evidence to show that the resident had been involved. Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 12 The care plans were not used as working documents and did not consistently reflect the care and support being provided for individuals. The consultant reported that care staff had been provided with the support to use care plans effectively however it was evident from discussion with care staff that further support and training was required. In the main, family members were happy with the personal care and support provided for their relatives at Windermere. Some reported that there were insufficient care staff on duty and consequently some areas of personal care were not always attended to. Some reported that their relatives sometimes look ‘unkempt’ and that people were often left sitting in wheelchairs as it took two staff members to transfer to an easy chair. Staff reported that much of their time during the week was involved with domestic duties and meal preparation. Healthcare professionals spoken with as part of this inspection process praised the home for the attentiveness of the care staff. It was reported that instructions were always followed and the staff were always polite and courteous. There were no incidences of pressure sores at the home. Medication was stored appropriately in a locked cupboard in the office. The home has changed the medication administration system since the previous visit. The acting manager reported there were ‘teething problems’, however these were being managed. There were some gaps in the medication records, the manager reported that she was aware that this was an issue and described actions she was taking to put this right. The training matrix provided at the inspection visit indicated that 6 staff members had received recent training in the safer handling and administration of medicines. Residents and family members reported they felt the carers promoted the dignity of individuals, however observation on the day showed that practice did not always confirm this. Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 13 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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A limited range of activities within the home and community meant the residents did not have a range of opportunity to keep them occupied. Staff chores mean that they did not have the time to spend with residents or assist individuals to access the community. EVIDENCE: Routines within the home were not flexible and staff indicated an unwillingness to change their way of working to adapt to modern care standards. Residents have become over compliant with the routine of the home consequently when they are asked if they are happy with their life they respond positively as they have no memory of any other regime. Staff reported that the residents had no wish to change the food menu, participate in activities, become involved in the daily running of the home or embrace any opportunities to take part in every day life. Staff were not able to demonstrate how the residents were supported to make these choices and in what manner the choices were communicated to the resident. Family members spoken with as part of this inspection process were very happy with care provided for their relatives however felt that the home could do more to provide stimulation for individuals. Discussion took place with the Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 14 acting manager and consultant around the provision of meaningful activities for people with dementia and where this information may be obtained. Family members reported they were able to visit the home at any time and were always made welcome. Residents were encouraged to bring personal possessions into the home to individualise their personal space. Residents were not encouraged or supported to access the kitchen to make a drink when they wished. The potential element of risk was the reason given for this, discussion was held with the acting manager around using the risk management framework to support residents to participate in the activities of daily living where possible as opposed to limiting their choice. It was discussed that some residents may have the capacity to become involved in preparing vegetables or other culinary tasks, a staff member reported that the kitchen was “no place for residents”. Activity records provided evidence that family members often took residents out into the community for walks or shopping. Some family members spoken with were not aware that ‘it was allowed’ for staff to accompany residents on outings from the home. Staff and family members reported that the staffing levels limited residents’ access to the community and limited the amount of activities provided by the home. The acting manager is aware that ‘choice’ has not been at the forefront of the ethos of the home and has started to introduce some changes. One resident had been supported to chair residents’ meetings and another to be secretary. There was a menu available however this varied little from week to week and did not provide residents with a choice. Residents could tell which day of the week it was by the meal provided. All residents spoken with said they enjoyed the meals. The majority of the food provisions and ingredients viewed during this inspection site visit were ‘economy’ standard from a supermarket. Staff reported that they have a petty cash float at the home to purchase fresh fruit and vegetables and the provider reported purchasing meat, pies and other essential items separately. Seven of the 11 staff employed at the home had received training in basic food hygiene in the past 3 years. Residents were served tea and biscuits mid afternoon. Staff were observed selecting biscuits for residents and handing them to the resident or placing them directly onto a side table. Discussion was held around allowing the residents to select their own biscuits and the use of side plates. This practice did not serve to promote the residents’ dignity. Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who lived at Windermere were able to express their concerns and had access to a complaints procedure however there was little awareness of what constituted a complaint amongst the staff and management team. EVIDENCE: The service had a complaints procedure that explained to residents and their representatives how to make a complaint. Staff demonstrated awareness of the complaints procedure however there was little awareness of what constituted a complaint and how complaints could be used in a positive way to drive the quality of the service provision forward. One complaint had been recorded since the previous inspection visit and had been dealt with appropriately. Policies and procedures for safeguarding people using the service don’t reflect correct procedures to be followed to protect the people living at the home. Training in the Protection of Vulnerable Adults had been provided for 10/11 staff members within the previous 12 months and the manager reported that 2 staff members were booked to attend refresher training. One staff member had been recruited since the last inspection visit; all checks necessary to protect the safety of the residents had been satisfactorily undertaken before this staff member commenced work at the home Windermere Rest Home DS0000065465.V336966.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the basic needs of the people who lived there. EVIDENCE: The registered provider has continued to make improvements to the home environment since the last inspection, however the décor remained dated and tired. The home has sought advice from the fire service and environmental department and the provider has met requirements highlighted by these professional bodies for example the installation of ramps to fire exits and new fire signage. A grant has been accessed to assist towards the internal décor of the home. The residents and their families have been in discussions with the provider Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 17 regarding replacement of the lounge/diner carpet and what colour to paint the walls. There is no budgeted or planned programme to improve the decoration, fixtures and fittings and maintenance tends to be reactive rather than proactive. Most areas of the home require redecoration and refurbishment; relatives reported that the provider encouraged them to redecorate their relatives’ bedrooms if they so wished. Residents reported the home was ‘comfortable’. The stairway to the first floor is extremely steep and narrow; residents are able to access the first floor by means of a passenger lift with the supervision of staff members. The bathrooms were noted to be ‘functional’ as opposed to attractive and appealing. A discussion was held with the acting manager around making these facilities more pleasant places to be. Radiators were guarded to protect residents from burning themselves apart from one in the home’s office and one in a communal hallway leading to the downstairs bathroom, the latter had fallen off and evidence was available to confirm that maintenance had been booked. Records were now being kept of the temperature at which hot water was delivered to promote residents’ health and safety and protect them from the risk of scalds. Relatives reported that there was not always sufficient hot water available. All areas of the home were clean and had no unpleasant odours. The home employed a dedicated member of domestic staff one day per week. It was reported that the home was cleaned thoroughly from ‘top to bottom’ on this day and the care staff had daily cleaning chores to maintain standards during the week. Relatives spoken with were concerned that standards had slipped and were that care staff were having to spend time doing domestic duties instead of providing care and support to the residents. Windermere Rest Home DS0000065465.V336966.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. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing was sufficient to meet the personal care needs of the people living at the home however levels were insufficient to ensure their social and spiritual needs were also met. EVIDENCE: The Provider had secured the services of a consultant to support the home through the recruitment of a new manager to post and to assist with achieving compliance with regulation. At the point of this site visit there was a new acting manager in post. During the previous inspection process some residents, relatives and staff felt that there were not enough staff on duty to meet the needs of the residents and that staff morale was low. It was reported that there were times when residents had to wait for staff support and attention and there was little attention to spiritual, social or religious needs. This situation had not changed however it was recognised that the home had suffered a period of no leadership whilst awaiting the appointment of an appropriate person to manage the service and relatives spoken with reported now feeling confident that some things were improving. Staff rotas provided evidence that staff were no longer working regular shifts in excess of 15 hours as previously found. Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 19 One waking person and one ‘sleep in’ person staffed night shifts. Discussion took place with the acting manager regarding the needs of the residents over the night time and whether this level of staffing effectively promoted and protected the health safety and welfare of persons living at the home. There was no detailed needs assessment to provide evidence that staffing levels are appropriate. Records showed that 45 of the staff had achieved or were working towards a minimum of NVQ level 2 in care, this falls short of the recommended ratio of 50 . . A recruitment file was seen for the last member of staff employed and it was found that all relevant checks to promote residents’ safety and well being had been undertaken with satisfactory result before the person started to work at the home. An individual training profile had been developed for all staff members and a matrix had been developed to provide an ‘at a glance’ record of the training provision across the staff team. This was not fully completed at the time of the inspection site visit however the acting manager was able to produce the required information in a timely manner. The fully completed records provided evidence that the service did not have a structured and budgeted programme of staff training. 8 of the 11 staff employed to work at the home had received specialist training to meet the needs of people with dementia however training in Manual handling, health and safety, first aid, fire awareness basic food hygiene and infection control had not been routinely or consistently provided in recent years. There was no evidence of a structured induction training provision. It was reported by staff, residents and family members that there were no longer opportunities for people living at the home to attend religious services, a volunteer organisation used to take people to church regularly but were no longer able to. It was reported that there were insufficient staff on duty to allow this activity to take place. Family members and staff confirmed that residents did not access the community as often as they would like and most family members spoken with were concerned that there was a lack of stimulation provided for their relatives at the home. Care staff were responsible for cooking all meals and undertaking routine domestic chores during the week. One resident was bed bound and needed two staff members to deliver personal care. Staff members need to stop cooking to assist people to the toilet or individuals have to wait until the other member of staff becomes free. Family members reported that their concerns around staffing levels had been raised with the provider at a relatives meeting and they had been told that the Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 20 home ‘meets’ the criteria. Residents’ social and spiritual needs are not being catered for currently. Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new management regime is beginning to have a positive impact with potentially good outcomes for the people who live there however the health, safety and welfare of the people living at the home could be better protected. EVIDENCE: The registered provider has recruited a manager. This person had been in post for 2 weeks at the point of this inspection and will be in the role of acting manager during the probationary period supported by the registered provider and a consultant. The acting manager has previous management experience and is working towards bring some stability and leadership to the service. Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 22 The quality assurance programme had not been developed since the last inspection however the acting manager demonstrated good knowledge of the processes to undertake. Residents’ money is stored securely and recorded appropriately. Records showed significant shortfalls in the training and refresher training in fire safety, health and safety, infection control, 1st aid, manual handling and food hygiene. Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X 3 2 STAFFING Standard No Score 27 2 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 X X 2 Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 24 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 OP9 Regulation 13(2) Requirement When medication is administered to people living at the home it must be clearly recorded to ensure that people receive the correct levels of medication. People living at the home must be consulted about their interests and a programme of activities and facilities for recreation must be provided. People living at the home must be supported to maintain links with the local community according to their wishes. This is a repeat requirement. The previous timescales of 01/04/06 and 31/03/07 were not met. All parts of the home must be 31/10/07 reasonably decorated and kept in a good state of repair. This is a repeat requirement. The previous timescales of 01/04/06 and 31/03/07 were not met. There must be enough suitably 31/07/07 qualified, competent and DS0000065465.V336966.R01.S.doc Version 5.2 Page 25 Timescale for action 31/05/07 2 OP12 OP13 16 (2) 31/07/07 3 OP19 23(2)(d) 4 OP27 OP30 18 Windermere Rest Home 5 OP33 24 6 OP38 12(1)(a) 23 (4) experienced persons working at the home to meet the needs of the people living there including sufficient domestic staff. This is a repeat requirement. The previous timescales of 01/06/06 and 31/03/07 were not met. The annual quality assurance 31/07/07 system for reviewing and improving the quality of care provided must be developed. This is a repeat requirement. The previous timescales of 01/04/06 and 31/01/07 were not met. The home must be conducted to 31/07/07 promote the health and welfare of residents and staff. This means providing Fire safety training, Manual handling training, Induction training, infection control training, First Aid training and health and safety training for the staff team. Risk assessments to be undertaken. This is a repeat requirement. The previous timescales of 01/04/06 and 31/03/07 were not met. 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 OP15 Good Practice Recommendations People living at the home should be provided with a choice of menu. Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Windermere Rest Home DS0000065465.V336966.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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