CARE HOMES FOR OLDER PEOPLE
Windsor Court 34 Bodorgan Road Bournemouth Dorset BH2 6NJ Lead Inspector
Trevor Julian Unannounced Inspection 31st October 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windsor Court DS0000032192.V353898.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 DS0000032192.V353898.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Windsor Court Address 34 Bodorgan Road Bournemouth Dorset BH2 6NJ 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) 01202 554637 01202 297554 info@win-court.co.uk www.win-court.co.uk Lyndale Healthcare Limited Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58) of places Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide the following category of service only: Care home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 58. 15th June 2007 Date of last inspection Brief Description of the Service: Windsor Court is located in a quiet tree-lined road in a residential area some three quarters of a mile from Bournemouth town centre with all the facilities that can be expected in a large town, e.g. banks, post office, shops, library and places of worship. Getting to the town centre requires negotiating a steep hill as does accessing public transport, although the nearest bus stop is within 200 yards of the home. Windsor Court was originally a grand gentlemens residence before being converted to a hotel and still retains many of the features and appearance of a building that was used for that purpose, although it is now registered as a care home, providing personal and nursing care for up to 58 older people. The home has a wheelchair accessible entrance area with a small lounge adjacent to the generous hallway. Further communal areas, comprising the spacious dining room, TV and quiet lounges are all located on the ground floor and furnished much as if the premises was still a hotel. All rooms have high ceilings and big windows. There is a secluded garden at the rear of the home that is mainly laid to lawn, surrounded by mature trees and a large car parking area at the front for visitors. Windsor Court is owned by Lyndale Healthcare Ltd, a family business. Management has been given over to BML Healthcare Ltd. Residents accommodation is located on the lower ground, ground, first and second floors of the home with access between floors via a wide staircase, passenger or stair lifts. Aids and equipment are available for residents who may have disabilities. The home is centrally heated throughout. All of the fifty eight bedrooms are for single occupancy, with fifty-three having their own enWindsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 5 suite WC. The remaining five comprise two pairs of bedrooms, with each pair sharing the en-suite facilities and one room that has an en-suite WC and wash hand basin. Windsor Court provides 24-hour personal care, all meals, laundry and domestic services. Residents are encouraged to participate in a range of activities organised in the home. A monthly inter-denominational religious service takes place in the home. In June 2007 fees for the home, as confirmed to the Commission for Social Care Inspection (CSCI) range from £442 - £700 per week. Additional charges include hairdressing, chiropody, dry cleaning, toiletries and newspapers. The Office of Fair Trading has published a report highlighting important issues for many older people when choosing a care home, e.g., contracts and information about fees and services. The CSCI has responded to this report and further information can be obtained from the following website: http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_ choosing a care home .aspx A copy of the home’s inspection report will be made available to anyone wishing to read it upon request to the manager. Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced inspection was started on the 31st October 2007 and was completed on the 13th November 2007. Trevor Julian, Chris Gould, Regulation Inspectors and Christine Main, pharmacy inspector, carried out the inspection. Since the last key inspection, there had been a series of 5 random visits to ensure the safety of the people living at the home. In that period, significant issues were discovered and the home’s management had been transferred to BML Healthcare LTD who were working to address those concerns. Because of the concerns, the registered manager and her deputy had been dismissed from the home. This had led to problems for BML Healthcare as there have been a number of people managing the service, which has meant there has been lack of continuity. Since this inspection, BML Healthcare have appointed a new manager and deputy to improve the situation. The main focus of the visit was to consider care of the residents, staffing and management systems. Information for this report was gathered through discussion with staff, residents and visitors, case tracking and a tour of the premises. What the service does well:
The home uses a monitored dosage system and most Medicine Administration Record (MAR) charts are printed by the pharmacy to safeguard people. One visitor said he could not fault the home or the services offered. There was clear evidence that the home was involving healthcare professionals at an early stage to ensure that health issues were correctly managed. The home was promoting improved nutritional intake and the home was routinely using diet supplements for those identified as at risk. There was a complaint procedure and people said they could express concerns to the staff. They were not clear about the procedure which could be publicised better. Most of the staff had received training from the local authority about how to respond to allegations or signs of abuse. Work on the extension had been completed and there had been improvements to the existing communal areas of the home. The rooms visited had been personalised by the occupants with either pictures or items of furniture. Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
Significant issues were found at the last inspection and further problems were uncovered during the series of random inspections. The major concerns related to care practice, nutrition and recruitment practice. BML Healthcare had imposed a voluntary ban on admission to the home while they resolved the problems. While progress had been made in several areas, significant improvements were expected once the home had introduced a strong management team. Care Plans remained poor with the information not held consistently, there was duplication and some of the care tasks were not clear; in some cases the actions identified had not been carried out. Some aspects of the medication policy need updating so that staff have clear procedures to follow. Directions for administering creams and medicines prescribed, “when required” could still be improved to ensure that people’s healthcare needs are met. The home needs to ensure that medicines storage complies with legal requirements and improve the monitoring of refrigerated storage.
Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 8 Residents said they were treated very well by all the staff, however the inspectors observed a member of staff entering a bedroom without knocking and waiting. The residents found the standard of food variable and most said they felt desserts could be improved. In one room on the upper floor the window opening was not restricted. This could pose a hazard to the occupant. In another room the radiator was unguarded. The home should ensure the risks from unrestricted windows and unguarded radiators are adequately assessed. The home was served by a call alarm system allowing residents to request assistance from staff. In one room visited, the call point was not accessible to the resident. As stated above the home had previously had significant issues which were being addressed by BML Healthcare, however as the new management team were not in place at the time of the visit there remained issues around consistency and leadership with the residents and staff confused by the considerable number of changes made since August 2007. 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 DS0000032192.V353898.R01.S.doc Version 5.2 Page 9 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 DS0000032192.V353898.R01.S.doc Version 5.2 Page 10 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): Quality in this outcome area was not assessed on this occasion. This judgement has been made using available evidence including a visit to this service. N/A EVIDENCE: No new admissions had been made since the last inspection due to a voluntary block on admissions. Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There had been limited progress made in improvements to health and personal care. The residents’ safety had been improved but more attention was required to ensure that the staff were clear about how care was to be delivered to meet the identified need. EVIDENCE: Several care plans were checked. They had not been fully reviewed by the home’s staff and several contained contradictory or out of date information. There was duplication of information e.g. a client handling assessment and a separate manual handling assessment making it difficult for staff to seek out relevant information. Some manual handling assessments did not identify which sling or hoist should be used, another stated that the residents mobilised with a walking aid, however staff were very clear that he was immobile. There was a bed rail assessment but there was no evidence of agreement with the individual or their representative. A care plan identified that the resident required “regular turns” to reduce the risk of pressure ulceration but did not
Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 12 specify how often. One person’s nutritional assessment identified a high risk and an action of weekly checks to monitor weights but these had not been recorded. Several other files showed that in recent weeks there had been weight gain as a result of improved care practice. This was also observed during the visit with fluid and nutritional intake being promoted by the staff. In one of the falls assessment there was a note that an air mattress was provided but this was not identified on the care plan. Fluid charts were incomplete. Several people had diabetes but the staff seen had not been trained in diabetes care and the files seen did not include normal ranges of blood sugars. Oral care was mentioned but not the tasks required to meet the need. There was evidence of improved access to healthcare professionals. A speech therapist was booked to visit several residents. Several people commented that the staff would call for GP visits if they needed and some said they had regular visits from community nurses for wound care etc. Three residents looked after some or all of their own medicines. The risk assessment for one person did not adequately cover safe storage to protect other people in the home and information about their eyesight differed with other parts of care plan. For example, the risk assessment indicated no problems but the care plan mentioned that staff needed to ensure that the person knew where their meal plate was because of poor vision. The manager said that they were obtaining more suitable storage for people who selfmedicated. The home has a medication policy but it did not include: checking and recording receipt of a new resident’s medication; ordering repeat medicines and household medicines list to give staff clear procedures to follow. Trained staff administer other people’s medicines and we checked 6 people’s records with the medicines in stock to see if they were given as prescribed, recorded and stored correctly. The home kept records of the quantities of medicines received. There was a good audit trail and the amounts in stock agreed with the records and indicated that medicines were given as prescribed. The quantities of medicines requiring special storage and recording agreed with the records. The dose directions for one “when required” medicine had been improved but did not state what the medicine should be given for. We saw clear information about applying a cream in one person’s care plan but the name of another was not mentioned and it was not recorded on their MAR chart so we were not sure if they were having the care prescribed. The home had made improvements to medicines storage following the previous inspection but one cupboard did not meet legal requirements. The temperature of the downstairs medicines room was above the recommended 25°C and needs monitoring and action to reduce it so that medicines do not deteriorate. Staff recorded the actual rather than maximum and minimum temperatures of
Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 13 the medicines fridge and the maximum reading at the time was high. The actual daily temperatures recorded were in the correct range. The dates of opening eye drops and medicines with a limited life were recorded so that they could be discarded when expired to reduce the risk of infection. The home had not complied with the immediate requirement about unsafe lancing devices used for blood testing made at a random pharmacy inspection but the acting manager disposed of the stock straight away. She said that the GPs had told them that it was no longer necessary for staff to test people with diabetes currently in the home in this way. Generally, the residents said that staff treated them with respect and dignity. In most cases a good rapport was noted during staff interactions. However, at one point of the visit we were with a resident and observed a member of staff entering the resident’s room without knocking on the door. Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 14 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, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were able to exercise a degree of choice in their daily lives but there remained room for further improvement. EVIDENCE: The care plans seen had variable information on social needs. Where they had been completed there was not always information on the way the needs were being met. Residents were seen joining in bingo. There were arrangements with local churches to provide religious services in the home. There was also a visiting library service offering a varied range of books and typefaces. People said there were choices offered in their daily lives. Since the last key inspection some of the visits focused on nutritional issues. There was clear evidence of poor practice, however by the time of this visit improvements were noted with staff actively encouraging people to maintain good intakes. One carer was seen going off to get some residents cream to make the their pudding more appetizing. Residents had mixed views of the meals provided with several very positive and an equal amount very critical.
Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 15 One commented “the same old vegetables all the time.” Another said “you don’t know what you are going to get half the time.” Others said “it was very nice and it had a nice sauce.” One person said that there had been improvements over recent weeks and there was always a good choice at supper time. Several people were on softened diets although it was not always recorded why this was. People felt they were not fully consulted about the menus and there was a lack of choice of dessert. Food stocks were good. The kitchen had been updated as part of the general improvements although there seemed to be a lack of work surfaces for the preparation of the meals. Windsor Court DS0000032192.V353898.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, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home’s systems allowed people to safely raise concerns. Adult protection training programme for staff should ensure that potential abuse cases can be correctly addressed. EVIDENCE: People said they were able to raise concerns with the staff but were confused by the recent changes of senior staff so they were not sure who they would go to for serious matters. Information was included in the service users guide. However, the procedure should be more widely publicised to make it more accessible for residents and visitors. The complaint file had records of complaints and compliments received in the home. Most staff were trained in adult protection procedures by the local authority. Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 17 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, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The premises generally provide a reasonable standard of accommodation. EVIDENCE: The building work had been completed on the new extension and improvements and redecoration had been carried out on the communal areas of the original building. Some of the older bedrooms would benefit from some attention and one person had recently moved rooms because of a water leak over his bed. The home was also trying to rectify ongoing problems with the heating system in part of the building. In one room visited, the bed was sited with the headboard towards the window leaving the occupant staring at a blank wall; this was addressed by the second visit. On the first visit, we found cleaning materials left out in a bathroom and Steradent tablets were also
Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 18 accessible to residents who could have confused them for medication. These matters were reported to the project manager of the time and were immediately remedied. At the same time, an unpleasant odour was noted near one of the ground floor bathrooms; this was investigated and also resolved. These matters were not seen on the second visit. The bedrooms visited had been personalised by the occupant with their own photos and items of furniture. There were call points allowing the residents to call for assistance as needed; in one room the point was not accessible to the resident. Most radiators did not pose a threat of burns to the residents but in some rooms uncovered radiators were seen. Risk assessments were not checked during this visit. It was also noted that one of the rooms visited on the upper floors had windows with unrestricted openings, which could also create a potential risk to the occupant. The laundry was located on the lower ground floor in the old part of the building. The laundry was well equipped with commercial washers and dryers. Bed linen was sent out to a commercial laundry service and the staff monitor the quality of the items returned. The housekeeper on duty said she had been trained in managing infection control. Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 19 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, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing ratios were good but work was needed to ensure that they were effectively managed. There had been some improvement to the training provided and the programme was being reviewed to ensure that staff had the required skills and training. Recruitment practice in the home had improved to ensure that new staff were suitable for the caring role. EVIDENCE: On the second day 12 staff survey forms were circulated to allow them to give their views. Only one was returned, it gave a positive view of the home. With the removal of the nursing patients, the staffing ratios were good. The staff team would benefit from having a consistent management team as they needed direction and support. Supervision of staff was re–starting. Residents had found the whole process unsettling but most seemed to feel that they were beginning to feel the benefits. Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 20 BML Healthcare had started to review the training programme for the staff to ensure that they had the required skill to provide appropriate care. The recruitment practice had been improved and the staff files were being reviewed to ensure the correct information was obtained. The files of new staff showed that required clearances and references had been obtained before they started employment. Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 21 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, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. With the introduction of a permanent senior team, with the required skills, the management issues will be considerably improved benefiting both the residents and staff. EVIDENCE: As stated previously the home had a number of staff taking control since August 2007. On the two days of the inspection, there were two different people in charge. BML Healthcare have now appointed a new manager and deputy who have been working at the home since mid November 2007.
Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 22 Throughout the period, BML Healthcare have kept the Commission and local authority aware of the changes and issues in the home. With the changes ongoing in the home, quality assurance and residents’ finances were not considered at this inspection. There had been improvements in the management of safety in the home. Approved contractors had serviced equipment seen in the home and there had been improvements to fire safety procedures although it was noted that a fire door into one bedroom was held open by a length of rope. Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 23 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x x x x x x 3 Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 24 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 OP3 Regulation 14(1) Requirement The registered person must ensure that an assessment is completed ensuring all needs can be met. This requirement had a previous timescale 31/08/07 and 30/09/07 2. OP7 12(1)(4) and 15(1) It is a requirement that all aspects of each resident’ s health, personal and social care needs must be recorded, including any psychological, social, cultural and religious needs. Care plans must make clear how these needs are to be met. This requirement had a previous timescale 01/07/07, 31/08/07, 30/09/07 Medicines storage must comply with legal requirements. Medicines must be stored at the correct temperature to maintain their effectiveness.
Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 25 Timescale for action 31/01/08 31/01/08 3. OP9 13(2) 31/12/07 There must be an effective system for ensuring that creams and emollients are applied as prescribed and recorded. There must be clear directions for how and when any ‘when required’ medicines are to be given so that staff know how to meet residents’ healthcare needs. Risk assessments for selfmedication must be regularly reviewed and updated where necessary to address the current risks. 4. OP9 13(2) The medication policy must be updated so that staff have clear procedures to follow on all aspects of the handling of medication in the home. The registered person must ensure that the care home is conducted in a manner which respects the privacy and dignity of service users. This requirement had a previous timescale 31/11/07 6. OP15 16(i) The registered person must provide in adequate quantities, suitable, wholesome and nutritious food which is varied and properly prepared and available at such time as may reasonably be required by service users. The training programme’s effectiveness and detail must be
DS0000032192.V353898.R01.S.doc 31/12/07 5. OP10 12(4)(a) 31/01/08 31/10/07 7. OP30 18(1) 31/01/08 Windsor Court Version 5.2 Page 26 appropriate to the work that they are to perform. 8. OP30 18(1) The staff training and development programme must be completed, to ensure staff have the training necessary to carry out their work. This requirement had a previous timescale 01/07/07 31/08/07 and 30/09/07. The registered provider must ensure that the service is managed by a person with relevant qualifications, skills and experience. The registered person must ensure that all staff are appropriately supervised. This requirement had a previous timescale 30/09/07. 31/01/08 9 OP31 9 28/02/08 10. OP36 18(2) 31/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The maximum and minimum temperature (normal range 2-8oC) of the refrigerator used to store medicines should be monitored and recorded daily when in use. Care plans for people with diabetes should include details of monitoring required, the person’s usual levels and when and what action to take if levels are outside their usual range.
Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 27 2. OP12 It is recommended that, where possible, further information about each resident’s background, social history, previous hobbies and interests etc. is recorded, to ensure that the activities on offer at Windsor Court will be meeting the individual needs, preferences and expectations of residents. Checks should be completed to ensure that windows above the ground floor and radiators are adequately assessed to ensure the risks to residents and staff are minimised. It is recommended that a minimum of 50 of care staff achieve NVQ level 2 training. The registered person should ensure that the Quality Assurance survey seeks the views of all stakeholders. The registered person should ensure that all records are legible, up to date and in good order. The registered person should ensure that accident reports are stored securely to comply with the data protection act. The accident reports should be regularly analysed to monitor for trends. 3 OP25 4. 5. 6. 7. OP28 OP33 OP37 OP38 Windsor Court DS0000032192.V353898.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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
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