Inspection on 13/06/05 for Windmill Lodge

This inspection was carried out on 13th June 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Windmill Lodge 11/04/07

Windmill Lodge 21/11/05

Windmill Lodge 13/12/04

Windmill Lodge 24/08/04

Windmill Lodge 13/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Windmill Lodge 2 Windmill Hill Buntingford Hertfordshire SG9 9JP Lead Inspector Jan Sheppard Unannounced: 10:00 13 June 2006 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Windmill Lodge Address 2 Windmill Hill Buntingford Hertfordshire SG9 9JP 01763 273935 01763 274303 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs M Alcock Miss J Hubbard Care Home 6 Category(ies) of LD Learning Disability - 5 registration, with number LD(E) Learning Disability - 1 of places Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13 December 2004 Brief Description of the Service: Windmill Lodge was a family house that was converted into a care home in 1995. It is situated at the end of a cul-de-sac in a residential area of Buntingford and is within walking distance of local amenities. The home, which blends in very well with the surrounding residential properties, comprises six bedrooms, two bathrooms, a shower room, two lounges, a dining room and a good sized kitchen. There are large gardens to the rear and side of the property and good parking to the front. The home, is owned by Hertfordshire County Council and is run by a private partnership, it offers a safe secure and caring environment for its residents who are adults with learning disabilities. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first unannounced inspection of the inspection year and took place over one day during which all the five service users currently resident in the home and all the staff who were on duty during that day were spoken with. A visiting NVQ tutor from a local college was also interviewed. Discussions were held with the homes manager and with the senior staff who came on duty. A tour was made of the building and of its garden and paddock area. This was a positive inspection; the inspector was welcomed into the home by the residents most of whom could remember previous inspection visits. All the residents made time to have their own individual discussion with the inspector and spoke in an empowered manner and very openly about their life in the home. They all appeared to be happy and relaxed and described various aspects of theirs lives at Windmill Lodge, which they were clearly enjoying. Since the last inspection a number of improvements, renovations and changes have been made to the buildings gardens and paddock area of the home and further works are either planned or are already in hand. These works along with the replacement of a number of pieces of equipment ensures that the smooth running of the home is maintained. There are no outstanding unmet requirements from the last inspection. What the service does well: The home offers a warm secure and homely environment for its residents with facilities and equipment that are appropriate for their physical and emotional needs. All the residents appeared to be relaxed and happy and to be very much at home in their own personal spaces. They were observed to be making their likes and dislikes clearly known to the staff and their empowered manner was seen to be clearly encouraged by the staff. The home has achieved a very good training standard with all the staff except one, now having attained, or are studying for, an NVQ level 2,3 or 4. Additional specialist courses are also attended and all staff spoken with were very positive about the training opportunities that the home offers them. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 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. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4and 5. The home has a Statement of Purpose and a Service Users Guide which gives appropriate information for the service users and their families concerning how the home operates and what procedures are in place to meet their existing and changing care needs. Some sections of this document have been prepared in a visual format, which the residents may have a better understanding of. EVIDENCE: The atmosphere in the home during this inspection was relaxed with the service users needs being met in a caring and enabling manner by staff who clearly knew them well and had a good understanding of their care needs as well as their wants, wishes, likes and dislikes. The home has a pre-admission policy and assessment procedure that meets the requirements of these standards. As there have been no new admissions to the home since the last inspection it was not possible to examine any current records relating to these standards. However the records relating to the last new admission to the home some two years ago evidenced that the policy was followed with an introductory timetable that took some three months and involved several visits including weekend staying visits as well as participation in social activities with the existing group of residents. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 9 The contract of Terms and Conditions given to every service user gives details of their room, the fees payable, the care and services that they will receive and the terms and conditions of their occupancy including their rights in the event of any breach of contract. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7and 9. Personal care and assistance offered to the service users is of a high standard and is given in a manner that maintains their dignity and respect. The home keeps comprehensive and imaginative care plans which are regularly reviewed so that changes to health and social care needs are recognised and met quickly. Risk assessments are maintained for all residents and these reflect how the potential risks for some individual residents can best be avoided or managed as safely as possible. EVIDENCE: The care plans examined evidenced that the residents are fully involved with their compiling and regular review. Residents who are able are encouraged to write their own comments on their plans whilst on others key workers had written comments directly quoting the residents requests and words. The records of the residents meetings gave good evidence of their determination and ability to make as many decisions about their own life style as it is possibly safe for them to do and how this was gently encouraged by the staff. Several of the residents spoke with the inspector about the choices they were considering as to where to take their summer holidays and how they might, finances permitting, be able to have two such staying away breaks. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 11 All the residents take at least one holiday each year, these sometimes being taken as a group and for others alone with a one to one or one to two staff ratio as required to meet their needs. Being a small home with a long-standing staff group the residents are able to have spontaneous and frequent discussions with all the staff in an empowered manner. The risk assessments on the care plans where the care needs have recently been subject to frequent change were found to be well maintained, with areas where a recognised risk had been judged to still be within acceptable bounds clearly described. For the resident who likes to walk backwards an agreement had been reached with him where it was safe and permissible for him to do this and where not. The inspector noted that many of the residents displayed a good awareness of safety issues both for themselves, their peers and for the staff. An uneven area of the patio, awaiting refurbishment, was pointed out as not in current use because of the risks of tripping. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16 and 17. The residents day care and social activity programmes offer them the opportunity for personal development alongside peers of a similar age and ability. The home provides a regular evening and weekend leisure activity programme that is discussed regularly with the residents and changed to meet their wishes and abilities and to suit the time of year. For those residents with relatives good liaison with the home is maintained including a regular visiting pattern. A nutritious and varied menu chosen by the residents and supervised by a dietician is offered with fresh ingredients and home cooking being provided on a daily basis. EVIDENCE: The records demonstrated that all the service users have their individual day activity programmes covering either four or five weekdays and all weekend days. These programmes are planned to meet the residents individual needs interests and abilities. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 13 The manager explained that since the last inspection because of the changing care needs and abilities of several of the residents, also because of the changes in provision of local day care and classes at the local college, these day programmes have had to be radically revised and new venues and activities sought. One resident spoke with the inspector about the class he attends at a local college whilst several others spoke very happily about the work that they were doing on the homes new “ paddock project “ which is now run entirely in house. The inspector was taken to see the vegetable planting area and the wild flower meadow that had been planted and the residents discussed the out door cooking that they are able to do. Risk assessments were completed for all these activities. Some of the residents returned home from their day activities during this inspection. They appeared to be happy and relaxed and quickly settled into a teatime routine, which was obviously familiar to them. One resident on entering the home came immediately to the office to enquire who was visiting the home, he had noticed the strange car in the car park, and then immediately asked to speak with the inspector which he did and also showed her his room. He did all this in a very empowered manner and it was noted that the staff who observed from a discrete distance did not prevent him in any way. The homes domestic style kitchen is very much, both physically and emotionally, the centre of this home. Some residents are able access the fridge and prepare drinks and snacks for themselves, one offered to make the inspector a cup of tea. The staff and residents were seen to mix very spontaneously in this kitchen area so that all could be involved to what ever extent they choose with the preparations for the evening meal. Since the last inspection and as part of their day activity programmes all the residents are now much more involved in the ordering and purchasing of the weekly groceries from a local supermarket which previously delivered the goods directly to the home. The staff commented on the various positive effects that this change had bought about for the residents who clearly from their comments enjoyed this shopping activity. The home continues to follow a healthy eating menu and receives regular supervisory visits from the dietician. For the one resident who is currently on a peg feeding regime a sympathetic pattern for managing this had been established which is being coped well with by the resident who is gradually gaining weight and looking much better in himself. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 20 and 21 Personal Care and Health Care offered to the residents is of a high standard and meets their individual requirements. Many of the staff have worked with these residents for many years and have an in-depth understanding of their care needs and of their varying moods and can interpret their wishes as to how these needs should best be met on any particular day. The home benefits from having well established professional working relationships with their local GPs, the community nursing teams and with various specialist consultants at the local hospital this ensuring that the residents changing health needs are properly met. The home has a robust medication administration and storage system and an appropriate system for dealing with the aging, illness and death of any service user. EVIDENCE: Individual personal care practice observed was commendable. The needs of the residents were seen to be being individually met by kind sympathetic staff who intervened as little as possible thus ensuring the greatest level of self determination for the residents. The records demonstrated that since the last inspection that for several of the residents who had required medical treatment in hospital, some of a complex nature, their care needs were now being successfully met in the home with appropriate support from community nursing and medical practitioners services. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 15 One resident whose return from hospital depended on the ability of the home to manage his “peg feeding” regime told the inspector that he was being very well cared for and that he was very happy to be back “at home” amongst his friends. There have been no changes to the homes medication administration system since the last inspection. This is supplied by a local pharmacist who carries out regular audits to check the management of the system within the home. The medication was found to be stored in appropriate locked cabinets and the MAR sheets, which are checked regularly by the homes manager, were seen to be accurately recorded. The manager does keep a records of these regular checks so they could not be fully evidenced during this inspection. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has the required complaints policy and procedures, a copy of which has been given to all residents and where possible also to their relatives and families. The home has policies and procedures concerning Adult Protection and Whistle Blowing, which follow the guidelines given in the Hertfordshire County Council Adult Protection Joint Agency procedures. EVIDENCE: There have been no complaints nor any incidents concerning Adult protection since the last inspection. The home has prepared a copy of their complaints procedure in a pictorial format, which has been shared with all the service users to ensure that they all have as best an understanding as possible of this. The residents in this home act in a very empowered manner and are not slow in making any complaints known. Staff spoken with demonstrated a good awareness of Adult protection and Whistle blowing a subject about which all had attended training and they also demonstrated an awareness of their role in picking up and interpreting any non verbal signs of concern or distress that they may exhibited by the residents. It was discussed that the senior staff member who is currently completing the A1/A2 Mentors training course attends, in an observing capacity, a strategy meeting so as to have a complete understanding of the investigation reporting and review process when an incident concerning adult protection is suspected and is being investigated. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29 and 30. The home and its surroundings offer a pleasant, comfortable and safe environment for the residents, which meet their needs and suit their lifestyle and fits unobtrusively into the community in which it is set. The home is clean and has a routine maintenance programme. EVIDENCE: The home a large detached house was renovated and adapted to become a care home in 1996. It is an attractive and very well maintained building. Each resident has a spacious bedroom supplied with specialist furnishings and equipment to meet their particular needs and to maximise their independence, this equipment provided following an Occupational Therapy assessment. All the bedrooms are well personalised with items that reflect the tastes and interests of each resident. One resident when asked what he liked about living in the home said “I like being in My Room.” On the day of this unannounced inspection the home was found to be clean and tidy with no unpleasant smells. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 18 Since the last inspection a considerable number of works of repair and refurbishment and the acquisition of new items of equipment have been provided in the home to provide a more comfortable and attractive environment, including the refitting of an old bathroom into a shower / wet room, redecoration in two bedrooms re-carpeting of two bedrooms and the lounge living room areas and the fitting of a new water softening system. Works to redecorate the lounge living room areas are to take place in July when all the residents will be away on holiday. The residents spoke to the inspector about the colours they had chosen for this area and showed her a swatch of the colour and fabrics chosen. The manager discussed with the inspector plans that are being worked out to enlarge and level the patio area thus making it safe and accessible for all the residents and also some refurbishment measures planned for the work shed in the paddock area. The home is situated at the end of an unadopted and unmade up road this being its only entrance. This roadway, which the home does not own, has developed a number of large potholes immediately in front of the entrance gate to the home. Staff complained to the inspector that these holes and the general unevenness of this roadway, which is gradually getting worse, was beginning to prove hazardous when the residents went out, especially for those in wheelchairs whose safety could not be guaranteed especially in wet weather when the holes become like ‘small lakes’. The inspector witnessed the homes large bus returning along this road and noted the very bumpy and hazardous conditions. The road must be repaired and the pot holes filled to ensure the safety of the residents and staff at all times. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,35 and 36. The home is run by a dedicated and well established staff team who are led by an experienced and qualified manager. The staff are all trained to meet the needs of the service users and undertake training on an ongoing basis. All the staff have job descriptions and clearly identified roles and responsibilities within the home. EVIDENCE: All the staff on duty were spoken with and without exception they all spoke positively about their work and about the regular supervision and training opportunities afforded them. The home is fully staffed with a stable well established workforce. Since the last inspection the home has made one new appointment the new staff member being an experienced carer who already holds a NVQ level 2 qualification. The recruitment records were examined and demonstrated that the correct policies and procedures had been followed as required to safeguard the residents. This new staff member who had only been in post three weeks spoke appreciatively of the detailed induction and initial training that he had been offered and also mentioned the fact that the good staffing level enabled the staff to work closely with the residents and to have enough time to offer them very good care. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 20 The staff rotas demonstrated that despite being without one resident who is in hospital the staffing level within the home had not been reduced. The manager discussed with the inspector the difficulties she is currently facing in appointing a permanent member of staff to the night team. During this inspection the staff were observed to be working well together as a team and to be appropriately anticipating the care needs of the residents and especially for one resident with limited speech who was having a discussion with the inspector, were on hand to cover any interpretation needs. The home has achieved a very high standard of NVQ training with all the care workers bar one holding an NVQ level 2 or 3 award. This far exceeds the 50 requirement for which the home is to be commended. Each staff member has an annual training programme this being linked to their monthly supervision records and to their annual appraisal. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 The home is well run by an experienced qualified and competent manager who leads a dedicated staff group who work well together as a team. The varying needs of the service users are kept under constant consideration by the staff this to ensure that their health safety and good welfare are maintained and also to ensure the continuance of the warm caring environment where the residents seemed happy and relaxed. EVIDENCE: The manager communicates a clear sense of leadership within the home and was well spoken of by the staff consulted on the day of this inspection. A senior carer spoke appreciatively of the help and support she had received during a recent period of maternity leave and the extra help that she had been given with her studies for the A1 award, whilst a newly appointed staff member commented on the time and discussions given by the manager during his induction training programme. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 22 The homes records relating to accidents and injuries, fire safety and appliance testing, regulation 37 notifications, risk assessments and financial procedures relating to the residents monies were all found to be kept in good order. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 4 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Windmill Lodge Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 24 no Are there any outstanding requirements from the last inspection? 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 24 Regulation 13 (4) (a) Requirement The home must arrange for repairs to be made to the potholes on uneven entrance roadway so to ensure the safety of residents and staff at all times Timescale for action 31/10/05 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. 2. Refer to Standard 20 23 Good Practice Recommendations It is recommended that the manager keeps a records of her management checks of the accuracy of the homes medication administration recording. It is recommended that the senior staff member currently studying for the A1/A2 award observes an adult protection strategy meeting so as to fully understand this process. Windmill Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City AL7 3BQ 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 Lodge I52 s19623 windmill lodge v232218 130605 stage 4.doc Version 1.30 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. 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