Inspection on 15/03/06 for Windmill House

This inspection was carried out on 15th March 2006.

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

Windmill House 09/03/07

Windmill House 18/03/05

Windmill House 30/11/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Windmill House Alveston Road Tockington South Glos BS32 4PH Lead Inspector Wendy Kirby Unannounced Inspection 15th March 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 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. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Windmill House Address Alveston Road Tockington South Glos BS32 4PH 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) 01454 413818 Windmill Care Limited Mrs Katharine Rachel Collacott Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 37 persons aged 65 years and over requiring personal care 8th September 2005 Date of last inspection Brief Description of the Service: Windmill House is registered as a private residential care home providing accommodation and personal care for up to thirty-seven older people aged sixty-five years and over. The home is owned and operated by Windmill Care Ltd a company owned by Mr and Mrs Collacot. Mrs Collacot is the registered manager. Windmill House is situated in the hamlet of Old Down, close to the village of Tockington where there are shops and other village amenities. The home is on a bus route to the town of Thornbury approximately two miles away where there are a variety of services and facilities. Transport is provided by the home. The home is a period, detached house set in its own grounds, which has been extended. An additional new wing was built in 2004 that provided a further seven en suite rooms and additional lounge space. The original house has three floors with many character features. The more modern extension to the house is on two floors. The new wing is at ground level. A passenger lift and stair lift provide access to all floors. There are well-established gardens that offer sitting areas and level walks with attractive features. Most rooms overlook the garden and communal areas have aspects into the garden. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process. The inspection lasted one day. During the inspection the inspector spent time in discussions with the manager, and examined a number of records, including four residents care plans, and records relating to the day-to-day running and management of the home. The inspector spent time observing the residents in the home throughout the course of the visit and spoke with several at length. Members of staff were observed on duty and one was consulted individually. The inspector had a cursory tour of the premises. What the service does well: What has improved since the last inspection? The home now operates a policy whereby written consent is gained from the resident or family for the use of bedrails. Following a requirement from the previous inspection, medication charts are maintained appropriately and show consistency in dispensing. Staff are currently enrolled in a distance-learning course on Medication Competency with Radstock College. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 6 Staff now receive fire training as part of their induction and annual updates are now taking place. An annual training matrix ensures that all staff receive mandatory training updates. 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. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 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 Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 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): 1,3,5 The prospective residents are provided with necessary information to help decide if the home is suitable. Prospective residents needs are assessed prior to admission to determine the suitability of placement to ensure that their needs can be met. Trial visits give prospective residents an opportunity to assess the nature of the home. EVIDENCE: The inspector looked at the home’s Statement of Purpose and a coloured brochure the home produces, which acts as a users guide. Information contained within this documentation includes services and facilities available and how to make a complaint about the service provided should this be necessary. The brochure details the home’s aims and the level of support the resident may expect. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 9 The manager uses a detailed assessment form from the ‘Standex’ system, which covers the activities of daily living and a dependency profile. The manager is a trained nurse and through her knowledge and expertise she is able to demonstrate a vast knowledge of the current residents, their medical history, personal background and their subsequent needs. The information gathered provides a sound benchmark of the resident’s ability and state of health prior to admission. The Inspector looked at four pre-admission assessments, which were completed fully and were informative. The prospective resident, family and carers are involved in the pre-assessment and all information is used to determine the suitability of the placement. Where possible the manager had also obtained comprehensive assessments and care plans from other professionals involved for example, social workers and hospital staff. Prospective residents are encouraged to visit the home either for the day or perhaps for lunch, dependent on their wishes. A month’s trial period on both sides is usually undertaken to ensure that everyone is happy with the arrangements and to ensure that the placement is suitable. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 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 The service had good systems for meeting and monitoring residents’ health and personal care needs in consultation with residents Staff have a good awareness of individuals needs and treat the residents in a warm and respectful manner, which means that they can expect to receive care and support in a sensitive way. EVIDENCE: The home uses the ‘Standex’ system of documentation for assessing, planning and evaluating care based on the activities of living. The documentation available was comprehensive and overall completed to a satisfactory standard. Risk assessments were in place with detailed information to ensure safe procedures for example, manual handling and the correct use of bed rails. Following a requirement from the previous inspection, the inspector looked at consent letters obtained from residents or their families regarding the use of bed rails. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 11 Records of the General Practitioner (GP) visits/contact with residents and the outcomes were also available. The home had access to pressure relieving equipment and this was documented in the plan of care. Specialist referrals and visits from other professionals were evidenced in care files including Community Nurses, Chiropodists, Opticians and Dentists. The Inspector was informed that each resident was referred to a GP of his or her choice on admission to the home and an initial first visit was then set up. Good working relationships with GP’s and District Nursing teams have been formed and they will visit on request. The home operates a key worker system (named worker). It was evident that residents had built positive relationships with their named worker and made comments such as “She’s lovely, my nurse, always looking out for me” and “I can tell them anything and they will help me”. Key workers are responsible for completing a weekly report and daily report record, however the care files evidenced inconsistency in this area. In discussions with the manager it was clear that these issues had been identified and some staff were in the process of being allocated responsibilities to ensure that all staff maintain records appropriately. Due to a requirement from the previous inspection, medication charts were examined and showed continuity in dispensing. Staff are currently enrolled in a distance-learning course on Medication Competency with Radstock College. The manager had also acquired a training video from the chemist on the MDS (Monitored Dosage System) used in the home. Staff were witnessed knocking on residents’ doors before entering confirming respect for the residents individual privacy and dignity at all times. The atmosphere in the home on the day of the inspection was relaxed. Staff, the manager and residents were observed to have good relationships. Staff responded to residents in a sensitive and professional manner. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 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 Residents benefit from a varied activities programme, which is both enjoyable, stimulating and meets individual preferences and expectations. Residents maintain family contact and staff encourage family and friends to join in with household activities. Relatives feel they can advocate openly on behalf on their relative. EVIDENCE: Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 13 In conjunction with the staff, the providers develop a monthly timetable of activities and forthcoming events. A copy of this is circulated to the residents and visitors and placed in communal areas throughout the home, to ensure that all are kept informed of planned activities. Residents take part in a range of social activities including cooking, arts and crafts, singing, and organised games. Residents spoken with expressed firm favourites such as arts and crafts particularly making things for special times in the year e.g. Easter and Christmas. Trips out have included going out for lunch, and trips to the theatre; recent productions seen have included “My Fair Lady”, “Aladdin” and “Fiddler on the Roof”. Through residents meetings spring trips have been planned to Thornbury arts Festival, Cadbury garden centre, and Weston Super Mare. At the last meeting residents expressed the wish to go on more shopping trips which will be arranged in the near future. Residents are supported with regards to their religious preferences, monthly communion is held at the home. At present three Roman Catholic residents are visited weekly and one lady attends the local Methodist church. The grounds and gardens are extensive and beautifully maintained at Windmill House providing the residents with various seating areas where they can take advantage of enjoying the country views when the weather permits. The home operates an open door policy for visitors. Residents were able to see visitors in the privacy of their rooms and there were several semi-private seating areas around the home. The hairdresser visits weekly. The home has six weekly residents meetings which are well attended and minutes are taken and circulated to residents and their families and placed on the notice boards throughout the home. Staff ask residents prior to the meeting if they have any issues they would like to discuss and any information they would like to share with the group. At the last meeting residents requested more curries on the menu, and suggested a variation of sandwich fillings such as avocado and salmon. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 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 There are robust and comprehensive policies in place to manage complaints. There are good arrangements in place for staff training and awareness of protection of vulnerable adults. EVIDENCE: A copy of the complaints procedure is on display in a well-frequented part of the home, which means people will know how to obtain the required information if they want to make a complaint. The complaints policy and procedure is detailed and contains all the required information. There had been no complaints received since the last inspection. Mrs Collacott, who is referred to as Katy by the residents, is the registered provider and manages the home. Any concern raised by residents and visitors is dealt with immediately; information of the outcome is cascaded down to the staff, through hand over time and recorded in the resident’s notes. Where necessary written confirmation of the outcome and how issues will be resolved is also sent to the relative and families and evidence of this was seen during the inspection. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 15 Relatives and their families are also invited to the six-monthly reviews, which also gives them the opportunity to discuss any concerns they may have. All staff receive training on the Protection of Vulnerable Adults by accessing the courses held through South Gloucestershire Council. The home also has an Abuse Awareness video, which, staff watch as a way of updating their knowledge and are required to complete a questionnaire afterwards. There are procedures as well as a range of guidance information on the topic of protection of vulnerable adults from abuse’. The availability of this information should increase staff awareness and understanding of their role in protecting vulnerable adults who live at the home. One staff member confirmed their understanding of the term abuse and made reference to the “whistle blowing policy. Staff confirmed that abuse and the policy is discussed during their induction. Resident’s confirmed during the inspection that they are well looked after and provided comments “Katy will always help me if I have a problem and things go wrong” and “My nurse is very good to me, I am so lucky to have her”. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,26 Residents would be better protected if the water temperatures in their rooms were within the safe recommended levels. Residents would be further protected if their bedroom doors were fitted with correct fire The home is clean, comfortable, well decorated and furnished. It provides a peaceful and well-maintained environment for the residents. The bedrooms and communal rooms and facilities are suitable and well presented for their purpose and meet the resident’s needs. EVIDENCE: Windmill House is a period-detached property that has been extended. It is set in very attractive spacious grounds and gardens. The owners have renovated and refurbished the home to a high standard while retaining several original character features. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 17 The accommodation is on three floors and access is either via a passenger lift or a stair lift. All residents are offered a single room. A number of rooms have en suite facilities provided. The remaining rooms are not en suite, but have hand washbasins and communal toilets are located in close proximity to all bedrooms. During the inspection the inspector tested water temperatures in some of the residents rooms. The water temperatures in some rooms were too hot and a requirement is made to ensure adequate provision is made to restore safe temperature levels. In the meantime a risk assessment must be developed for each room where the water is too hot to ensure that residents, staff and visitors are safe. All areas of the home were clean and well maintained. Great attention has been given to ensure that all areas are homely. Residents had been supported to personalise their bedrooms with pictures and ornaments. The manager stated that residents are able to bring items of furniture should they wish. The home offers a variety of communal areas looking onto the well-tended garden. There was a sun lounge, a hobby/library room, a smaller and larger lounge and the hallway had comfortable seating. Residents were making full use of these areas and their bedrooms on the day of the inspection. A number of residents said how much they liked the views of the gardens and surrounding fields, trees and wildlife from their bedroom windows. It was noted that some of the bedroom doors were propped open either with furniture or a wedge. This practice was discussed with the manager who explained that some residents prefer to spend a large amount of the day in the privacy of their rooms but also like the doors to be kept open to enable them to acknowledge staff, visitors and fellow residents who are passing by. Although the inspector could sympathise with the residents this practise must stop immediately and the home must obtain suitable equipment as recommended by the Fire Brigade to enable doors to be kept open safely. The home had adequate bathing facilities that had been fitted with equipment to encourage the independence and the safety of the individuals living in the home. The home was clean and free from unpleasant odours. The home employs domestic staff on a daily basis with reduced cover at weekends. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29,30 Residents are supported and protected by the home’s recruitment policy. The residents are cared for by skilled staff that are trained and supported by management. The relationships between staff and residents are good and create a warm positive environment to live in. EVIDENCE: The recruitment process was examined and all staff records examined showed that the home follows a recruitment procedure. Records contained application forms, references, and a CRB (Criminal Records Bureau) disclosure. There were no staff vacancies at the time of the inspection. There is an induction programme, which covers all mandatory training, including Fire, Manual Handling, Health and Safety and the Protection of Vulnerable adults. The home has a mentor system where all new staff are linked with and shadow a senior staff member during each shift to enable continuity and continued training throughout the induction process. The home continues to support their staff with their NVQ levels 1 and 3 and the enrolling programme continues. The manager and her staff are conscientious in attending training relevant to the care needs of the residents. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 19 This year the team are focusing on training in “Parkinson’s Awareness”, “Dementia Awareness and Behaviour that Challenges”. All mandatory training was up to date. The inspector spent some time throughout the day sitting in the communal areas observing staff carrying out their duties and assisting residents. Staff were respectful, warm in manner, good humoured and sensitive towards the residents within a relaxed, calm environment. One staff member spoken with demonstrated a true dedication to her role and responsibilities to the residents and home. Morale in the home appeared good with the staff working well together. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 20 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): 31,33,34,36,37,38 The home is well managed and there are good relationships within the staff team and with residents and relatives. Residents, visitors and staff would be better protected if all staff receive fire drills at the recommended intervals. EVIDENCE: Mrs Collacott is the registered manager and co-owner and has run Windmill House with her husband since 1998. She has overall charge of the day-to-day running of the home and is in the home most days. Mrs Collacott explained that she has a dedicated team who work with her to ensure that the highest standards of care are achieved and maintained. Mrs Collacott is a registered general nurse who demonstrated a good understanding of the needs of the individuals living in the home. Mrs Collacott has gained an NVQ 4 in management and is an NVQ assessor. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 21 Staff stated that the manager was very approachable and gives good direction and supports them. There was a high degree of satisfaction expressed by all of the residents spoken with. Based on the comments made and through the inspectors observation it is evident that residents feel the home is run in their best interests and to ensure their needs are being met. There were supervision records on staff files and the manager stated that she was aiming to complete this every 6-8 weeks. Supervision of staff will be eventually shared with the deputy once she has completed training and has gained the skills to enable her to supervise staff. One staff member confirmed that they felt supported by the manager and that she regularly worked alongside staff in a supervisory capacity. Although supervision was not quite up to date in discussions with the manager it was evident that the home was working hard at developing a plan with new initiatives for supervision, including group supervision and practical supervision to ensure that the standard for supervision was achieved. The policy and procedure for holding residents pocket money was examined and three individual accounts were looked at. It was evident that good accounting methods are adopted which account for all transactions documented and receipts for sundries were available to see. Policies and procedures for the home were examined and do not evidence that they are reviewed annually. The policy on complaints and whistle blowing held information that was out of date. Records showed that not all staff had received the appropriate fire drills as recommended by the Fire Prevention Officer and that all night staff undertake this on a three-monthly basis, and day staff six-monthly. Some of the Health and safety records in the home were examined. Documentation showed that relevant checks were maintained correctly and at the required intervals including all fire alarms and equipment. Emergency lighting and water temperatures had not been checked at the required intervals. As mentioned previously in the report, risk assessments must be developed to ensure the safety of residents, staff and visitors when using water in the rooms where the water is too hot. The home’s records showed all necessary service contracts were up to date including, gas and electrical services, and manual handling equipment. Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 22 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 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X 3 3 X 3 STAFFING Standard No Score 27 X 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 X 3 2 2 Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 23 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 OP19 Regulation 23 (4) (a) Requirement Discontinue the use of wedges or furniture used for propping open bedroom doors. Provide suitable equipment as recommended by the fire brigade. Submit to CSCI an Action Plan as to how adequate hot water facilities are to be restored throughout the home so that needs are met and safe practice is resumed. Policies and procedures for the home must evidence that they have been reviewed and updated as required. All staff must attend a drill within two weeks and thereafter every three months for staff on nights and every six months for staff on days. Previous Requirement. Risks assessments must be completed by the manager with regards to excessive hot water temperatures to ensure residents, visitors and staff safety and a copy should be sent to CSCI Timescale for action 15/03/06 4 OP21 23 2j 02/05/06 3 OP37 17 16/05/06 3. OP38 23(4)(e) 15/03/06 5 OP38 13 (4) c 02/05/06 Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 24 5 OP38 13(4) c Maintain monthly checks on water temperatures and emergency lighting. 15/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Windmill House DS0000003337.V278020.R01.S.doc Version 5.1 Page 26 - 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. 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