Inspection on 05/10/06 for Windermere Rest Home

This inspection was carried out on 5th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 18/04/07

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 Christine Bennett Key Announced Inspection 5th October 2006 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.V313339.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.V313339.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 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.V313339.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Date of last inspection Random Inspection 21/04/06 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.V313339.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key site visit was announced and took place on 5th October 2006 over an 8-hour period. A return visit was made on 10th October 2006 for a 2-hour period to spend time with the residents of the home. At this inspection all the key standards and the progress since the last inspection were assessed. Information from a random inspection in April 2006 is also included in this report. A pre inspection questionnaire had been completed by the home prior to this visit, and surveys sent to residents, relatives, and general practitioners. The two registered providers, the deputy manager and the assistant manager were available throughout the day to assist with the inspection process. A tour of the premises took place and a random selection of records and policies were examined. Time was spent with the residents, observing care practices, and conversation took place with most of them and any visitors to the home. A district nurse and two relatives were also visiting the home and gave their views. Staff were also given the opportunity to speak with the inspector. Feedback was given throughout the inspection process. What the service does well: Many of the staff have worked at the home for many years and the staff team knew all the residents well. One of the relatives said, “On the whole the staff go out of their way to be kind”. The home makes sure that it is suitable for people, by visiting them in their own home and inviting them and their relatives to visit the home and spend some time there before they decide to move in. Windermere Rest Home DS0000065465.V313339.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Windermere Rest Home DS0000065465.V313339.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 Windermere Rest Home DS0000065465.V313339.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. Training must be developed for staff to evidence that they have the skills to perform their job. EVIDENCE: The home has an up to date Statement of Purpose and Service User Guide. These are available to people who might want to move in to the home. One relative said, “We were given a brochure and viewed the inspection report”. A contract stating the terms and conditions is given to each resident who moves into the home. The assistant manager has developed an assessment form to obtain as much information as possible about a prospective resident and their needs. A copy of this was seen in the care plan of somebody who had recently been admitted to the home. Windermere Rest Home DS0000065465.V313339.R01.S.doc Version 5.2 Page 9 Residents and/or their relatives have the opportunity to visit the home before they move in, and a senior member of staff visits them in the community to make sure that it can meet their needs. A relative commented, “We sent for information and we did visit prior to admission – we were made to feel welcome and the home felt homely”. One month after admission, a review is held with all the relevant people to make sure it is a suitable placement and the resident’s position is made permanent. The home is registered to cater for people with dementia but not all staff have had training in this and other specialist areas to demonstrate that they have the skills and ability to care for individual needs. The home does not provide intermediate care. Windermere Rest Home DS0000065465.V313339.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Care plans do not have enough information to ensure that residents’ needs will be met. EVIDENCE: Each resident has a care plan but staff confirmed that this is not a working document, and information relating to residents is recorded in the daily records, which have good information, a communal diary or other charts. The plans have basic information but there were shortfalls in the recording of risk assessments, the management of risks and some care needs. Residents and relatives are not involved in the care plans. Staff had a very good knowledge of individual residents and their needs. They were concerned that they are not always able to give the care that is required and gave an example of having to interrupt the cooking of lunch, in order to assist a resident to the toilet, as there are only two members of staff on duty late morning. Windermere Rest Home DS0000065465.V313339.R01.S.doc Version 5.2 Page 11 Residents have access to health care services both within the home and in the community. The district nurse was visiting during the site visit and said that her team had no concerns relating to the care that residents receive at the home. Two GPs who replied to a survey in May also had no concerns and said that the staff are cooperative. The home seeks professional advice on health care issues and there was evidence of the chiropodist, continence advisor and optician having input into the care. However basic care needs cannot always be evidenced as being met, such as the recording of weights. One relative was concerned about the “general cleanliness” of their relative and another said, “standards are slipping”. Residents and relatives were generally complimentary about the staff team and said they were kind and caring to them and respected their dignity. Comments received were, “very friendly and do their best” and “the staff worked hard with us to get the medication right and to help them settle in”. It was noted at the site visits that residents were seen by the GP or nurse in the privacy of their own rooms assisted by a member of staff. One resident has their own phone installed in their bedroom and the home has a cordless phone to enable other residents to take calls in private. The assistant manager confirmed that residents receive their mail unopened. Disposable gloves are on view in residents’ rooms and in the upstairs hallway. Medication records were not completed adequately for staff to be accurate about the medication received, administered and disposed of in the home. Creams prescribed for three residents were found in the rooms of other residents. Training must to be updated for staff who administer medication. Windermere Rest Home DS0000065465.V313339.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. A limited range of activities within the home and community means the residents do not have a range of opportunity to keep them occupied. Staff chores mean that they do not have the time to spend with residents. EVIDENCE: The home has a pleasant, friendly atmosphere and residents were seen to be chatting to each other in the lounge. Some residents choose to spend time in their room. The home provides a limited range of activities and most residents spend their day watching television. Any activities that are organised are chosen by the staff and have not included the residents’ choice and preferences. Any outside contact with the community is limited to special occasions such as a carol service that is provided by the local church at Christmas. Many of the residents spoken with expressed a desire to go out, such as shopping, a walk in the park or to have an ice cream on the seafront. Both the residents and the staff confirmed that this cannot take place due to lack of staff. Residents rely on relatives for any outings from the home. Visitors are welcomed into the home at any time. Staff confirmed that time spent preparing food or doing other chores in the home such as laundry and paperwork reduced the amount Windermere Rest Home DS0000065465.V313339.R01.S.doc Version 5.2 Page 13 of time they were able to spend with residents and relatives commented when talking about activities, “we have been told that they do not have the time or enough staff to be able to do these things anymore”, “treats like hairdressing or chiropody are not as available as they used to be” and “there is no interaction apart from basic care”. The home recognises that they are not meeting the residents’ needs in this area and are in the process of identifying outside clubs and social events and have spoken to residents about their preferences and intend to speak to relatives at a forthcoming meeting. The food is cooked by the care staff and training is needed in food handling and the relevant food legislation. The menu is available in the kitchen but is not freely available to residents. Residents have very little choice at meal times, although the staff are aware of individual likes and dislikes. Comments from residents and relatives varied about the food provided. They included, “The food I’ve seen looks ok”, “they are very happy with the food provided”, “all the meals look and smell appetising, with portions adequate for the appetites of residents” and “there is no choice of food”. One resident said that they have to wait for breakfast because the staff are busy assisting residents and haven’t got time to make it until they have finished. Windermere Rest Home DS0000065465.V313339.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Shortfalls in documentation could potentially put the residents at risk. EVIDENCE: The home has an up to date complaints policy, which is available in the Service User Guide. There have been no complaints recorded in the complaints book. However during the site visit the inspector was made aware of a concern that had been raised by relatives but had not been documented. The registered providers have attended training relating to POVA. Evidence must be submitted to CSCI to confirm that this condition of registration has been met. The assistant manager is a trainer of POVA and confirmed that all staff except one have received this training. Staff seen had a good knowledge of abuse and the reporting of abuse. The policy and procedures relating to POVA must be updated and available to staff. There have been no allegations or concerns reported at the home. However one survey from a visitor indicated that poor practices had been seen by them. This is being followed up by CSCI. Windermere Rest Home DS0000065465.V313339.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a homely atmosphere but areas need to be addressed to make it a safe environment for residents. EVIDENCE: The registered provider has made many improvements to the home environment since the last inspection. These include a new cooker and freezer, new kitchen cupboards and work surface, radiator covers to all radiators and mixer valves on taps to ensure water is delivered at a safe temperature. Records must be kept of the temperature at which hot water is delivered. There are still areas of the home that need attention and the provider has been asked to supply a programme of redecoration to CSCI. Comments from relatives included, “décor outdated” “looks worn and tired” and grown a little shabby over time”. During the site visit it was noticed that some bedroom curtains were not hanging properly, and a bedside cabinet was broken. Windermere Rest Home DS0000065465.V313339.R01.S.doc Version 5.2 Page 16 The home has sought advice from the fire service and environmental department and the provider is in the process of meeting the requirements highlighted by these professional bodies. These include the installation of ramps to fire exits and new fire signage. The communal areas of the home are clean and have no unpleasant odours. Two of the residents’ bedrooms had offensive odours. A relative commented, “The home is cleaned top to bottom on a regular basis”. The laundry has no safe working practice to tell staff about safe handling of soiled articles and washing temperatures in order to control infection. Some bins in the home did not have lids and soiled gloves were exposed. The home has installed liquid soap containers and paper towel dispensers in the laundry and communal areas and protective clothing is available in the laundry. Windermere Rest Home DS0000065465.V313339.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The home needs to show improvement in recruiting, deployment of staff and staff training in order to improve the outcomes for people using this service. EVIDENCE: The manager left the home in August 2006 and the registered provider is advertising to find a replacement. Existing staff are covering her working hours and the duty rota evidenced that some staff are working excessive hours or long shifts in excess of 15 hours. Some residents, relatives and staff felt that there were not enough staff and that staff morale is low. One relative commented, “recently the staff show low morale and standards are slipping – they are not getting the basic things done now as previously”. And another said, “staff morale has been low which in turn affects the other residents and the smooth running of the home. I feel the standards of the home are slipping, they may be cutting back on essential things”. The recruitment file was seen for the last member of staff employed and for a potential new employee. Shortfalls in these files included incomplete application forms, inadequate references and a POVA 1st check that was obtained after the employment start date. The home must have a thorough recruitment practice in place to protect the residents. Windermere Rest Home DS0000065465.V313339.R01.S.doc Version 5.2 Page 18 Four members of staff have an NVQ qualification level 2 or above in care. This equates to 40 of the workforce. There were shortfalls in the training of staff. One member of staff who had joined in March 2006 had not had an induction programme and had only had manual handling training to date. People who work in the kitchen had not got up to date training in food hygiene and health and safety. Not all staff had received updated training in basic areas such as manual handling, first aid, medication and fire safety. Many staff had not received specialist training in areas such as dementia, catheter care, pressure sores, bedrails, falls prevention etc. although they were caring for people with needs in these areas. Staff must have an individual training and development assessment and profile. Windermere Rest Home DS0000065465.V313339.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 Quality in this outcome is poor. This judgement has been made using available evidence including a visit to this service. The home lacks stability and must develop a quality assurance programme to evidence that it is run to suit the residents. It must adhere to health and safety regulations to protect the residents. EVIDENCE: The home has not had a registered manager since August 2006. The deputy manager and the assistant manager are being supported by the registered provider to fulfil this role until the appointment of a new manager. Although these two staff members are competent, they are inexperienced at running the home. Staff felt that it was not possible for managerial duties to be carried out efficiently due to the shortage of staff to give care. Some surveys from relatives’ felt that the home had deteriorated and the staff lacked leadership. Windermere Rest Home DS0000065465.V313339.R01.S.doc Version 5.2 Page 20 They were unsure who was in charge of the home in the absence of a manager. Staff also seemed unsure about future plans relating to the running of the home. Staff supervision is taking place and evidence was seen in staff files. The quality assurance programme had not been developed since the last inspection. Staff meetings were erratic although resident’s views were sought at monthly meetings. A relatives meeting had been planned for October 2006 and the registered provider intended to be present to discuss future plans and answer any concerns they might have. The registered person has not compiled a written monthly report on the conduct of the home since he became the owner in October 2005. Residents’ money is stored securely and recorded appropriately. Files checked at random were accurate. The health and safety of the residents must be protected by safe working practices in the home. This includes updated training in infection control, fire safety, first aid, manual handling and food hygiene. Temperatures at which hot water is delivered must also be recorded on a regular basis. The policies and procedures of the home must be reviewed and accessible. The registered person has sought the advice of the fire department and is in the process of fulfilling their requirements to meet legislation. Some fire doors were wedged open at the site visit. Windermere Rest Home DS0000065465.V313339.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 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 1 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 3 X X X 2 2 STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 3 x 2 Windermere Rest Home DS0000065465.V313339.R01.S.doc Version 5.2 Page 22 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 OP4 Regulation 12 (1)(a) Requirement The registered person must promote and make proper provision for the health and welfare of prospective residents. This refers to staff having the skills to do their job. The registered person must prepare a written plan with consultation with the resident/ relative as to how needs will be met. This particularly applies to risk assessments and their management and reviews. This is a repeat requirement. The previous timescale of 01/04/06 was not met The registered person must make provision for the care and supervision of residents. This refers to basic care needs, including regular weighing, nutritional charts and chiropody. The registered person must make arrangements for the safe administration of medicines. Timescale for action 31/03/07 2. OP7 15 31/01/07 3. OP8 12 (1)(b) 31/01/07 4. OP9 13 (2) 31/12/06 Windermere Rest Home DS0000065465.V313339.R01.S.doc Version 5.2 Page 23 5. OP12 16 (2) (m)(n) 6. OP13 16(2) 7. 8. OP16 OP18 22 Schedule 4 13(6) The registered person must consult with the residents about their interests and provide a programme of activities and facilities for recreation The registered person must make arrangements for residents to maintain links with the local community according to their wishes. The registered person must maintain a record of complaints and action taken The registered person must make arrangements to prevent residents from being abused. This refers to the policies and procedures being in place and known to staff This is a repeat requirement The previous timescale of 01/08/06 was not met The registered person must ensure all parts of the home are reasonably decorated and in a good state of repair. A programme of redecoration must be provided to CSCI The registered person must ensure that all parts of the home are as far as reasonably practicable free from hazards and that unnecessary risks to residents are identified and as far as possible eliminated. Hazards and risks identified are: The regulating and recording of water temperatures. The use of bedrails. This is a repeat requirement. The previous timescale of 01/09/06 was not met 31/03/07 31/03/07 31/12/06 31/12/06 9. OP19 23(2)(d) 31/03/07 10. OP25 13(4)(a) 31/12/06 Windermere Rest Home DS0000065465.V313339.R01.S.doc Version 5.2 Page 24 11. OP26 13(3)16 (2) (k) The registered person must make arrangements to prevent the spread of infection and ensure satisfactory standards of hygiene. This refers to the laundry area and odour control This is a repeat requirement. The previous timescale of 01/07/06 was not met 31/01/07 12. OP27 18(1) (a) 12 (5) (a) The registered person must 31/03/07 ensure that at all times there are suitably qualified, competent and experienced persons working at the home in such number as are appropriate for the health and welfare of the residents. Staff should maintain good personal and professional relationships with each other in relation to the home. This is a repeat requirement. The previous timescale of 01/06/06 was not met The registered person must operate a sound recruitment programme as detailed in Schedule 2 This is a repeat requirement. The previous timescale of 01/06/06 was not met 31/12/06 13. OP29 19(1) 14. OP30 18(1) c (i)(ii) The registered person must 31/03/07 ensure that staff receive training appropriate to the work that they perform. This includes an induction programme, health and safety, basic training and specialist training to suit the individual needs of the residents. This is a repeat requirement. The previous timescale of 01/06/06 was not met The registered person must appoint an individual to manage the home DS0000065465.V313339.R01.S.doc 15. OP31 8 (1) 31/03/07 Windermere Rest Home Version 5.2 Page 25 16. 17. OP32 OP33 10(1) 24, 26 The registered person must carry 31/01/07 on the care home with sufficient care, competence and skill. The registered person must 31/01/07 maintain a quality assurance system for reviewing and improving the quality of care provided. The registered person must prepare a written report on the conduct of the home and supply a copy to the CSCI monthly. This is a repeat requirement. The previous timescale of 01/07/06 was not met. 18. OP38 12(1)(a) 23 (4) The registered person must ensure that the home is conducted to promote and make provision for the health and welfare of residents and staff. This includes • Prevention and control of infection in the laundry • Hygiene and cleanliness in the kitchen training. • Fire safety • First Aid training • Risk assessments to be undertaken 31/03/07 Windermere Rest Home DS0000065465.V313339.R01.S.doc Version 5.2 Page 26 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 OP10 Good Practice Recommendations The registered person is recommended to ensure disposable gloves are stored discreetly to protect the privacy and dignity of residents. The registered person consults with the residents regarding their meals, offering them choice and an available menu. Nutritional/fluid charts should be developed for residents who have been risk assessed to need them. A minimum ratio of 50 of care staff should achieve NVQ2 or equivalent. 2. OP15 3. OP28 Windermere Rest Home DS0000065465.V313339.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 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.V313339.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!