Inspection on 19/02/07 for Windsor Court

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 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

Windsor Court 23/02/10

Windsor Court 09/02/09

Windsor Court 19/02/08

Windsor Court 24/05/06

Windsor Court 07/12/05

Windsor Court 06/06/05

Windsor Court 02/11/04

Windsor Court 10/05/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOMES FOR OLDER PEOPLE Windsor Court The Avenue Wallsend Tyne & Wear NE28 6SD Lead Inspector Aileen Beatty Key Unannounced Inspection 09:30 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 Windsor Court DS0000028829.V320359.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. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windsor Court Address The Avenue Wallsend Tyne & Wear NE28 6SD 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) 0191 263 5060 0191 263 3472 Mr Baldev Singh Ladhar Vacant Care Home 45 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (35), Learning disability (3), Mental disorder, of places excluding learning disability or dementia (1), Mental Disorder, excluding learning disability or dementia - over 65 years of age (4) Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 of the LD beds are currently occupied by named residents. If any of these residents vacate the beds, the Commission for Social Care Inspection must be notified, when action will be taken to revert those places to the category DE(E). 1 MD bed is currently occupied by a named resident. Once this resident leaves the home the Commission for Social Care Inspection must be notified when action will be taken to revert that place to the category DE(E). One short stay respite bed can be used for one specified resident as agreed category LD, otherwise it is category DE(E). 1 DE bed is currently occupied by a named resident. Once this resident leaves the home the Commission for Social Care Inspection must be notified when action will be taken to revert that place to the category DE(E). 24th May 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Windsor Court is a purpose built three storey Care Home providing both Nursing and Residential care for up to 45 service users. Categories of care are Dementia, Learning Disabilities and Mental Disorder. The home provides care for service users above and below 65 years of age. The home is situated in The Avenue, Wallsend, close to the High Street, giving ease of access to shops, stores, restaurants and other public amenities. The fees range from £360 per week to £370. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days. Two inspectors were present on day one. One inspector ate lunch with residents, looked around the home and read records. The standard of care in the home is generally good and there has been an improvement in many areas. An inspector also spent time in the lounge with staff and residents. What the service does well: What has improved since the last inspection? What they could do better: Care records must be stored confidentially. Sluice doors must be kept locked to keep residents safe. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 6 The garden area needs to be tidied so that it can be used by residents. All training must be brought up to date. 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. Windsor Court DS0000028829.V320359.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 Windsor Court DS0000028829.V320359.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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A detailed pre admission assessment is carried out with all residents before they are admitted to the home. EVIDENCE: A very detailed document is available for staff to use to assess new residents. This assessment makes sure that the home is the best place to care for the person and identifies any specialist help they may need. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 9 The person carrying out the assessment is usually the manager or deputy. Details of next of kin, social worker and GP are recorded. Very detailed information about health and medical history, sleep patterns, any history of mental health problems and behaviour are all gathered. This helps the home to get a very clear picture of the needs of the person. The communication needs of the resident and hobbies and interests are recorded. The above helps staff to write plans about how the person should be cared for before they arrive in the home. This is good practice. A new resident arrived in the home during the inspection and was tearful and apprehensive. They were given a warm welcome and were soon smiling and appeared much more relaxed. Windsor Court DS0000028829.V320359.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. Health and social care needs are recorded in individual care plans. Health needs are appropriately met. Medication procedures in the home are satisfactory. Residents are treated with dignity and respect. EVIDENCE: The format of care plans has been changed. All files containing care records are now in the same format and paperwork has been reviewed and changed. Consistency in this area has improved and files are neat and tidy and information is much easier to find. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 11 Regular care plan audits are taking place to check they are sufficiently detailed and are updated regularly. Managers provide regular reports about the standard of care plans relating to pressure sores. The care plans of four residents were read. These were chosen because the residents concerned have quite complex physical or psychological needs. They were found to be well written with a number of assessments carried out to help staff to write these plans. Assessments follow the Roper Logan and Tierney model of activities of daily living. This breaks down all of the activities a person needs to carry out each day (such as eating and drinking, and personal cleansing and dressing) and staff assess how much help the person needs with these or whether there are any problems. From these assessments care plans are written and regularly reviewed. There was some evidence that in a small number of cases, the care plan had been reviewed but the assessment had not. This has already been picked up during a management audit and has been addressed. Filing drawers containing records are not always kept locked which means confidentiality of information is not always maintained. Health needs are met. Residents have access to a GP and specialist nursing care if they need it. A chiropodist and optician visit the home regularly. A record of professional visitors to the home is kept. Social information is held in care records and this includes a “This is Your Life” section where information about the persons past is held. Family members usually complete this, although when there are none, staff try to complete as much as possible. Weight records and attention to nutrition has improved. Residents below 50kg are monitored and a new list of nutritional needs is displayed in the kitchen. New scales have been bought. Medication procedures are followed. The treatment room where medicine is stored is clean and tidy but would benefit from some shelves to keep files off the benches. This makes it easier to keep the benches clean. The medicine trolleys were organised and contain only items that should be there. The fridge items were correctly stored and the temperature checked regularly. There were no gaps in medication records and where medication was not given, the appropriate code was entered. A check of controlled drug Temazepam was carried out and the correct amount was found in stock. There had been a problem with ordering however, meaning that too much was delivered and had to be disposed of. The deputy manager explained that she was aware of why this had happened and had taken steps to prevent it happening again. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 12 Residents are treated with respect. Staff were observed caring for residents and an inspector spent time in the lounge with residents and staff. Staff were polite and good humoured. They were able to communicate well with the residents and dealt well with some challenging behaviour. One member of staff was seen sitting texting on a mobile phone. While this may have been a one off occurrence it is recommended that staff are all reminded that mobile phones should be left in lockers while they are working and a policy devised. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff try to offer experiences that meet the cultural, social, religious and recreational needs of residents. Residents are encouraged to maintain social contacts with friends and families. Residents are encouraged to exercise choice and control over their lives. Meals are prepared and presented well although dining areas are not all satisfactory. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 14 EVIDENCE: An activity coordinator is employed and a good range of activities are offered. In addition to planned activities there are various objects of interest around the home available for residents to explore at their leisure. This is good practice as people with dementia sometimes find it difficult to be involved in more formal activities due to limited concentration. It is very important that they are then given access to things they may find interesting in a more spontaneous way. For example, a table in the lounge has various objects books and puzzles on for people to explore. There are tactile boards on the walls in corridor with various interesting objects attached. Residents are involved in meaningful daytime activities and according to their individual interests and capability. A keep fit instructor comes in every fortnight to do exercises with residents and this proves very popular. Residents on the top floor were playing a game of skittles, which they were clearly enjoying. Music was playing loudly in one lounge for a very long period and it is recommended that this be monitored as people in there are unable to switch it off or ask that it is. At one point the TV was on at the same time which was very distracting. The new “This is your life” information held in the file of each resident allows staff to plan activities relevant to the person’s interests and previous life experience. The care file of one resident held photographs and newspaper cuttings about their life, which is a very useful tool for activity planning and reminiscence work. Newsletters are now published which keeps residents and visitors informed of events in the home. Staff now have access to an activities website which the home has invested in subscribing to. This gives staff ideas for new activities and is a very useful resource. There is evidence that the site has been used in the activity planning process. Relatives visiting the home said they are able to visit in private and are very happy with the care provided. The menu is varied with a number of choices including a healthy option. It includes a variety of dishes that encourage individuals to try new and sometimes unfamiliar food. The meals are balanced and nutritional and cater for the varying cultural and dietary needs of the individuals using the service. A record of special diets is held in the kitchen. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 15 Tables are now fully set and glasses have been provided instead of plastic beakers which are much more age appropriate and pleasant to use. The dining area on the ground floor in particular has been rearranged and is a much more pleasant room to sit in. Fruit is now available in fruit bowls for residents to help themselves to. Care staff are sensitive to the needs of those residents who find it difficult to eat and give assistance with meals. They are aware of the importance of helping at the pace of the resident, making them feel comfortable and unhurried. The inspector ate with residents and the meal was served at the correct temperature and was tasty and filling. Some dining rooms upstairs are too small to accommodate all residents living on that floor should they all wish to eat in the dining room. This is a potential problem and managers have been asked to consider what to do if this situation does arise. Currently some resident prefer to eat in their room or in the lounge by themselves. Some new menus for the tables have been printed which is good practice. It is recommended that some of these are available in large print. The kitchen has been redecorated and a number of new items of equipment including knives and a lid for the fryer have been provided. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 16 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. Complaints are taken seriously and acted upon. Service users are protected from abuse by the homes policies and procedures. EVIDENCE: The service has a complaints procedure that is clearly written and easy to understand. The complaints procedure is supplied to everyone living at the home and is displayed in a number of areas within the service. Residents and others involved with the home understand how to make a complaint and are clear about what will happen if a complaint is made. A leaflet explaining the complaints procedure is available so people visiting the home may take this with them instead of them having to make a note of the complaint procedure – they can take it away to read at their leisure. This is good practice. The home keeps a full record of complaints and this includes details of the investigation and any actions taken. Unless there are exceptional circumstances the service always responds within the agreed timescale. Complaints recorded since the last inspection (two) have been responded to appropriately and recorded fully. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 17 The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. Staff working at the service know when incidents need external input and who to refer the incident to. The home understands the procedures for Safeguarding Adults and have attended meetings or provide information to external agencies when requested. There are a low number of referrals made as a result of lack of incidents, rather than a lack of understanding about when incidents should be reported. The outcomes from any referral are managed well and issues resolved to the satisfaction of all involved. Training of staff in the area of protection is regularly arranged by the Home. Other training around dealing with physical and verbal aggression is also made available to staff as needed. All staff including kitchen and domestic staff must attend adult protection training which is good practice. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a generally safe and well maintained environment. The home is generally clean and hygienic. EVIDENCE: The home provides a physical environment that meets the specific needs of the people who live there. The home is comfortable, and there has been a major investment programme to improve the decoration, fixtures and fittings. Although this was initially as a result of pressure from contracts and CSCI inspections, a firm commitment has been given to sustain and further improve the environment in the home. This will be monitored. Many areas in the home have been redecorated, and new carpets have been supplied. The lift is in working order. A programme for further improvements is available and managers have been given training regarding planning and budgets. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 19 People who use services can personalise their rooms. There has been some consultation with service users about the décor, especially for their own rooms. Two relatives spoke to the inspector and wanted to specifically record their satisfaction with the cleanliness in the home. They are very happy that is clean and odour free. Toilets for the use of people using the service are appropriately located within the home, are easily accessible and in sufficient numbers. They would benefit from picture signage as well as writing as some people with dementia may respond better to a visual clue than written word. Some toilet flooring is due for renewal and must be completed as part of the ongoing refurbishment programme. A damaged wicker chair must be removed from one bathroom. Although it looks nice it may damage skin if someone sits on it as it is quite sharp. The wooden toilet seat in the top floor bathroom is marked and scraped and must be replaced. A new bath hoist has been provided. There was a fabric chair in the in the shower room on the middle floor that was damaged and marked. It must be removed. Shelves must also be secured to the wall. Bathrooms have been made more homely and inviting in appearance with colour and old fashioned Pears soap adverts. One resident spoken to said she would like a new wardrobe, drawers and bedside cabinet that matched. The manager was informed and agreed that this could be arranged. New bedding has been purchased. The home is generally clean and tidy. On the first day of the inspection, some residents were suffering from vomiting and staff put in place appropriate measure for dealing with an infection outbreak. Fortunately it was not that serious, but staff demonstrated that they knew what to do in the event of an outbreak. There were no paper towels or bin in one bathroom. There was a mild odour problem in two rooms. These are due for replacement carpets so this should hopefully be resolved. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are sufficient staff to meet the needs of residents. Residents are in safe hands at all times. The recruitment policy in the home ensures that residents are safe. Staff are not all fully trained and to do their jobs at present. EVIDENCE: Staff rotas show that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the people who use the service. Staff members undertake external qualifications beyond the basic requirements. Managers encourage and enable this and recognise the benefits of a skilled, trained workforce. Accurate job descriptions and specifications clearly define the roles and responsibilities of staff. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 21 There are consistently enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity. Staff training plans were previously out of date. The service is currently ensuring that all staff receive relevant training to meet the individual needs of people using the service. Safety training is being prioritised. A training matrix is displayed on the wall which quickly identifies training that has been completed, training that is due to run out and training that is out of date using colour codes. The plan of training that has been booked and training delivered has been provided to CSCI and is satisfactory. The new system will ensure that training is delivered on time in the future. The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. The files of two staff were checked and found to contain all of the required information. There are clear contingency plans for cover for vacancies and sickness and there is little use of any agency or temporary staff at present. It has been identified during a recent review that more qualified nurse hours are required. A post has been advertised as a result. Staff meetings take place regularly. Supervision sessions are regular and staff find them helpful. Notes are taken of meetings and sessions. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 22 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): 31,33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A new manager is in post and has not yet been through the CSCI fit person process. The home is run in the best interests of residents. Residents financial interests are safeguarded. Health safety and welfare are generally promoted and protected. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 23 EVIDENCE: The Manager has the required qualifications and experience but has not yet been assessed as competent to run the home through CSCI’s fit person process. Since being in post, the manager has demonstrated that she is skilled and experienced and will go through the formal process of assessment soon. The management in the home has changed significantly since the last inspection. There is a new home manager in post and also a new Director of Ladhar homes. In a growing organisation this has strengthened the existing management team and has proven effective so far. There is a strong ethos of being open and transparent in all areas of running of the home. The managers are person centred in their approach, and lead and support the staff team effectively. Policies and procedures have improved. The manager ensures staff follow the policies and procedures of the home. The staff team are more positive in their approach and translate policy into practice. Efficient systems are now in place to monitor staff adherence to policies and procedures during their practice. Management processes ensure that staff receive feedback on their work through regular supervision and appraisal. Staff reported that they are happy to come to work and have found that the atmosphere has changed in the home for the better. Managers are now given more training regarding business planning and budget management. Residents financial records were checked and found to be satisfactory. Safety procedures in the home are adequate but require further development to ensure complete compliance. There is evidence of regular electrical testing and servicing. It was noted that the gas landlords certificate was a little out of date and this was renewed promptly. Systems must be in place to ensure lapses do not occur in future. Other regular safety checks include windows, water temperatures and emergency lighting and fire equipment. There were a number of requirements made by the fire officer during an inspection in February, which must be addressed. Care must be taken to ensure that all sluice doors are kept locked. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 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 X 3 X 3 X X 2 Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 (1) 17 (1) (b) Requirement Care plan assessments must all be kept up to date. Care records must be stored confidentially. 2. OP15 23(1)(a) Review dining arrangements 19/05/07 upstairs to plan what to do in the event of all residents wishing to eat in a dining room. Damaged and fabric chairs must 19/04/07 be removed from the bathroom Picture signage must be added to bathroom doors. Shelves in bathroom must be secured to the wall. Confirm that refurbishment programme has been completed. 4. 5. OP26 OP38 13(3) 13(4)(a) Paper towels and waste bins must be provided in all hand washing areas. Comply with the requirements of the fire officer. 19/04/07 19/04/07 Timescale for action 19/02/07 3. OP19 13(2)13 (3)23(2) (d) Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 26 6. OP30 18(c)(i)10 (3) Review maintenance plans to ensure regular servicing and safety maintenance is carried out on time. Staff training must be brought 19/07/07 up to date. 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. 3. Refer to Standard OP19 OP12 OP10 Good Practice Recommendations It is recommended that shelves are provided in the treatment room. Staff monitor the use of the TV and radio being used at the same time. A policy regarding use of mobile phones at work should be devised and enforced. Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Windsor Court DS0000028829.V320359.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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