Inspection on 19/02/07 for Windlesham Manor

This inspection was carried out on 19th February 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

Windlesham Manor 01/11/05

Windlesham Manor 03/05/05

Windlesham Manor 09/01/05

Windlesham Manor 07/09/04

Windlesham Manor 27/06/02

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Windlesham Manor Hurtis Hill Crowborough East Sussex TN6 3AA Lead Inspector Debbie Calveley Key Unannounced Inspection 10:30 19th February 2007 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 Windlesham Manor DS0000021291.V322335.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. Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windlesham Manor Address Hurtis Hill Crowborough East Sussex TN6 3AA 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) 01892 652470 F/P 01892 652470 Mr Simon Carey Mrs Susan Carey Mrs Yvonne Peskett Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of residents to be accommodated will be forty (40) The residents will be aged sixty five (65) or over on admission Date of last inspection 1st November 2005 Brief Description of the Service: Windlesham Manor is a care home providing personal care and accommodation for up to 40 older people with low to medium dependency needs. The registered providers are Mr S & Mrs S Carey who have owned the home since 1982. The home is located on the outskirts of Crowborough, adjacent to Crowborough Beacon Golf Course. There are local services and facilities in the town, which is about one mile away. The house, which is a listed building, is a large extended two-storey country property. It stands in its own grounds that are laid with paths so that service users can walk in the gardens. The majority of bedrooms are well in excess of the recommended minimum standard size. All have ensuite facilities. There are two passenger lifts to the first floor plus a chair lift on one small flight of stairs. On the ground floor there are two lounges, a large dining room, and a conservatory, which has increased the communal space available for residents. Information on the range of fees charged was confirmed in the pre-inspection questionnaire prior to the inspection with fees approximately ranging from around £371 to £550 per week with extra changes for personal items. Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Windlesham Manor will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home and follow up contact with resident’s representatives and visiting health and social care professionals. This unannounced inspection was carried out over 5 hours on the 19th of February 2007. There were thirty-nine residents living in the home on the day of the inspection, of which fourteen, both male and female were spoken with, as were two relatives. The purpose of the inspection was to check that the requirements of previous inspections had been met and inspect all other key standards. A tour of the premises was undertaken and a range of documentation was viewed including the Service Users Guide, Statement of Purpose, care plans, medication records and recruitment and training files. Four members of care staff and the chef were spoken with in addition to discussion with the Registered Manager. The pre-inspection questionnaire was received back from the registered manager on the 02 January 2007 completed in full. Comment cards received from ten residents/relatives were generally positive and indicated that both groups were satisfied with the services provided. One comment card was received from a social and healthcare professional. The information contained in the returned surveys has been incorporated into this report. What the service does well: The health and social needs of the residents were met and the standard of care is of a good standard. The residents enjoy living in the home and comments received included ‘ This is the perfect place, everybody is so kind’ ‘ there is nothing to complain about’ ‘ the staff look after me very well’. The medication practices within the home are safe and competent. Systems are in place to regularly consult with residents via resident meetings. There is an open-house policy, which welcomes visitors at all reasonable times. Staff provision is well maintained with a robust recruitment practice being followed and appropriate numbers of staff working in the home. The atmosphere of the home is pleasant with good interaction seen between residents and staff. ‘Staff are friendly and caring’ ‘ the staff are wonderful’ The residents are enabled to exercise the choice and control of their every day life. Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 6 There is a variety of good nutritious food offered. Meals are taken in comfortable and homely surroundings. Feedback regarding the provision of food was positive and included ‘ excellent choice’ ‘ fresh and well presented’ Windlesham Manor provides a clean, safe, comfortable and well-maintained environment, which is appreciated by the residents and their relatives. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Windlesham Manor DS0000021291.V322335.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 Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are provided with information about the home in order to make an informed choice about whether to live at the home. The pre-admission assessment procedures ensure residents admitted can have their care needs met within the home. EVIDENCE: There is a range of information available about the home and the services it provides. This includes a combined Statement of Purpose and Service User Guide. Surveys received from residents stated that they had received information about the home before making a decision. However, it was discussed during the inspection that the residents and one visitor spoken with were not familiar with the Service User Guide documentation. Whilst it is understood that not all the residents admitted to Windlesham Manor will have use of these documents, it would benefit the residents, relatives and visitors if Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 9 up to date copies are more readily available for easy access to pertinent information. The manager confirmed it will be discussed at the next resident’s meeting. A social care professional confirmed that relevant information was provided to a prospective resident. A review of the care documentation confirmed that pre-admission assessments are completed, and are currently completed by the manager and assistant manager. These assessments were found to be satisfactory and were used to ensure any new admissions to the home is suitable and that the home have the staff and environment to meet the care needs of any new resident. The information contained in these assessments is used to provide the basis of the care documentation in the home. For future reference when reviewing individual residents it may be beneficial to document where the pre-admission assessment took place and who was involved. The manager and staff are aware of the registration category of the home. Prospective residents and their family are actively encouraged to visit the home and accommodation is initially offered on a trial basis. Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning evidences regular reviews, however there remains a need for the care plans to more clearly identify what action staff need to take to meet the specific needs of residents. Medication practices are competent and safe. EVIDENCE: The manager and staff of Windlesham Manor are knowledgeable regarding the personalities and needs of the people they care for. The care plan format is clear and straight forward to use, however the identified needs of the residents need to have a clear action plan that staff follow to meet the care need identified in a consistent safe manner to ensure positive outcomes. Five residents individual plans were viewed in depth and there was evidence of regular review for all the residents. However there is no evidence of resident or family consultation either on formation of the care plans or on the review. Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 11 Daily notes are written in a diary, it would be beneficial for all documentation relating to each resident to be kept in the one folder to enable visiting health professionals to access all residents’ information. An area that needs to be developed further is risk assessments for identified needs such as moving and handling and nutrition. They need to reflect any changes noted by staff as they happen and detail strategies for staff to follow. Whilst there are requirements regarding the care plans and risk assessments, the outcomes for the residents were good. Relatives spoken to were very satisfied with the care provided at the home one saying that the home ‘should be commended for its care’. Residents spoken to were also very satisfied, comments included’ I am very happy and content here’ ‘ I am so well looked after’. From talking to the residents it was evident that they are supported and enabled to see their doctor, chiropodist and district nurse in the privacy on their own room. The midday medication round was observed and evidenced that good practice was used in the administration and signing for medications. There are policies and procedures in place for the storing, administrating, disposal and receipt of medication; these were last reviewed in 2006. All staff that administer medication receive training from the dispensing pharmacist During the inspection the residents were seen being cared for with respect and kindness and their dignity being protected at all times. Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to remain as independent as possible and maintain control over their daily lives. There are suitable arrangements for occupation and stimulation. Links with families are valued and supported by the home. Residents spoke positively about the meals provided. EVIDENCE: Through out the inspection residents were observed being able to spend time where and how they wanted, moving around the home freely. Set routines are avoided as far as possible and residents are able to determine when they would like to go to bed and what time they would like to get up in the morning. This was confirmed during chats with the residents living in the home. A resident confided that she had breakfast in bed whilst another said she came downstairs to the dining room. Residents are able to choose whether they want to join in the activities provided, which are available in the afternoons and include art and craft sessions, exercise classes, knitting club, quizzes and crossword sessions and a gardening club as well as various social events. The activity co-ordinator was Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 13 seen in the morning chatting either with individual residents or joining groups and then a group went for a walk around the gardens. The residents were very complimentary regarding the co-ordinator, ‘ he is very kind’ ‘ nothing is too much trouble’ ‘ he takes an interest in all of us’. Residents and their representatives felt the activities and entertainment provided was satisfactory. On speaking to residents and visitors it was clear that visiting is very positively encouraged with no restrictions being imposed. Two visitors expressed a satisfaction that staff made them feel welcome whenever they visited. The menu was viewed and demonstrated a varied and balanced diet. The menu does not evidence a choice, but the chef and manager confirmed that the residents can choose from a selection of alternatives on a daily basis. The mealtime observed was unhurried and enjoyed by the residents. The dining area is comfortable and attractive with thought given to seating arrangements. The meals are served from a Bane Marie and therefore residents do have the opportunity to change their mind and also to choose the size of their meal. The meal of the day was jacket potatoes with a choice of three toppings and fresh vegetables followed by sponge pudding and custard. Feedback from the residents and from surveys received were complimentary regarding the food at Windlesham manor and include ‘ the food is very good’ ‘ always a high standard’ ‘ the meals are always beautifully cooked and served with alternatives ‘there is a very good varied menu’ ‘well cooked and nicely presented and as much as you want’. The kitchen was discussed with the manager as the floor and equipment are in need of deep cleaning and maintenance attention. The manager confirmed that this is known and is an area that will be addressed. Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a satisfactory complaints system, which is accessible to residents, relatives and staff. Staff receive training to protect residents from abuse. EVIDENCE: There are appropriate policies and procedures in place regarding complaints, and it was confirmed that these are followed when investigating any concerns raised at Windlesham Manor. The staff spoken with were knowledgeable regarding the complaint procedure and of how to start the process if the manager is not available. No complaints have been received by the CSCI or in the home since the last inspection. The Adult Protection policy in the home was found to be up to date and staff interviewed were knowledgeable about the systems in place to protect vulnerable service users. It was confirmed that there is on-going training for all staff in Protection of Vulnerable Adults. Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, clean and safe environment for those living there and visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. There is specialist equipment in the home for residents’ use to maximise their independence. EVIDENCE: Windlesham Manor provides a well-maintained, safe and comfortable environment for its residents. A full time maintenance person is employed and there is a rolling plan of decoration and repair. All bedrooms all have an ensuite facility, there are four double rooms available and one resident that shares a bedroom informed the inspector that the Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 16 second bedroom has been made in to a lounge area for them, ‘which is really nice’. Bedrooms are situated on two floors of the home and the first floor communal areas include two lounge areas, conservatory and dining room. The standard of furniture, fixtures and fittings is good and appreciated by the residents and their families. Comments received verbally during the inspection include ‘ it’s a lovely home, very comfortable’ ‘I have a lovely room and the whole home is kept beautifully fresh and clean at all times’. There was evidence of residents being encouraged to personalise their rooms with their own belongings and pieces of furniture. The bedrooms are clean, comfortably furnished and pleasantly decorated; all residents are offered the choice of a door lock to maintain their independence and privacy. There are adequate bathing facilities with specialist equipment, which enables frail residents and those with a physical disability to enjoy the facilities available. Specialised equipment to encourage independence is provided e.g. handrails in bathrooms, hoists, wheelchairs and lifts to all areas of the home. Call bells are provided in all areas. One resident said that she is encouraged and supported in regaining her mobility safely. The lighting in the home is of domestic quality. Water temperatures are controlled and monitored regularly and a record kept. Random temperatures were taken and were of the recommended level. The laundry room is well organised and clean. The standard of the laundry was mentioned in surveys as ‘very good’ ‘ look after my clothes very well’. Polices and procedures for infection control are in place and are updated regularly. The home was clean and free from offensive odours on the day of the inspection. The following comments were received from resident surveys, ‘no nasty smells around and always very clean’, ‘My relatives remark upon the lack of smell of any disinfectant’. Good practice by staff in the use of gloves and aprons were observed during the day. Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing arrangements are good and suitable and ensure the needs of the residents living in the home are met. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: From direct observation on the day of the inspection there were sufficient staff to meet the documented needs of the residents. The staff spoken with stated that they considered the staffing levels sufficient to do their jobs competently and felt confident that the manager would increase the staffing levels if required. The staffing levels at night consist of three waking carers. The recruitment process was found to be robust; four staff files of employees were examined and were found to contain all the necessary documentation and Criminal Record Checks. The manager confirmed that all staff complete an induction programme in line with Skills for Care, however the four seen had not been completed. The manager is to ensure that these are completed in full. From discussion with the manager it was confirmed that staff receive training in order to perform their job competently. However it was difficult to ascertain from the documentation seen and from talking to staff whether all staff have Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 18 received the training required. A training matrix that defines clearly the status of training needs to be developed. At present just under 50 of staff have a National Vocational Qualification; this is an on-going process with both the manager and the deputy manager being NVQ assessors. Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of this home is good with effective systems in place to protect service users. EVIDENCE: The Registered Manager has the experience to run the home effectively with support from the providers, the deputy manager and the staff team. The Registered Manager has been in post for nineteen years and does not have a management qualification. However this was discussed in depth and it is an area that is still under discussion, but a member of the management team will be enrolling on a management course in the near future. Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 20 The feedback from residents, relatives and staff indicated that they felt supported and were able to approach the management team at any time, ‘ I can talk to the staff, and they listen’ ‘ always supportive’ ‘ very approachable’. The ethos of the home is to focus on the residents and the staff were observed doing this. Regular staff meetings and resident/relative meetings are held and records of the meetings are kept. The staff mentioned the staff meetings and how beneficial they were and the staff felt that areas of improvement they put forward were acted for the benefit of the residents. These form part of the quality assurance systems in the home. One resident mentioned that they attended the resident meetings and thought it gave them the opportunity to discuss the running of the home and areas that could be improved. Residents’ financial interests are safeguarded by the homes policies and procedures. The home does not have any involvement with the resident’s finances. The manager confirmed that all staff are kept updated on the Health and Safety policies. All relevant legislation and procedures are in place in respect of Health and safety. Staff were able to discuss some of the training they received and said that they were kept up to date with changes to policies in connection with fire safety and health and safety. The staff are issued with certificates yearly for Moving and Handling, twice yearly for Fire Safety. From discussion with the staff and management team, regular formal supervision sessions with staff has yet to commence. Throughout the inspection good practice was observed in regards to ensuring the safety and well being of the residents when being moved around the building. The accident forms were seen and had been correctly completed with appropriate referrals made as necessary. First aid boxes are accessible and well stocked; fifteen members of staff hold a first aid certificate. Windlesham Manor DS0000021291.V322335.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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 X 3 Windlesham Manor DS0000021291.V322335.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 OP7 Regulation 15 Requirement The care plans need to have a clear plan of action documented for staff to follow to provide consistent care and support and promote independence. That the service users are consulted and involved in preparing a written plan of care. 2 OP8 12(1)((b) 13(1) The risk assessments relating to identified health needs need to be developed with a clear plan of action for all staff to follow. Detailed risk assessments need to be undertaken in respect of service users environment and include the management of risks. 3 OP30 18 That the manager ensures that all staff have completed an induction programme and receive training appropriate to the work they are to perform. That all care staff receive formal supervision at least six times a DS0000021291.V322335.R01.S.doc Timescale for action 30/04/07 30/04/07 30/04/07 4 OP36 18 (1) (2) 30/04/07 Windlesham Manor Version 5.2 Page 23 year as under Regulation 19 (1) (a-c). 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 OP19 OP15 Good Practice Recommendations That the kitchen floor and equipment is deep cleaned, that the cleaning rota is completed regularly and the maintenance of the kitchen is improved. Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone Kent ME16 9NT 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 Windlesham Manor DS0000021291.V322335.R01.S.doc Version 5.2 Page 25 - 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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