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Inspection on 12/12/05 for Windsor House

Also see our care home review for Windsor House for more information

This inspection was carried out on 12th December 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Clear policies and procedures are in place that are well organised, maintained and accessible to all. All staff have recently received and completed their annual appraisal. The deputy manager has commenced her Registered Managers Award. The atmosphere throughout the inspection was calm and friendly, promoting a good relationship between staff and service users. Staff spoken with during the inspection were complimentary of the management style within the home. The ethos of working openly, honestly and with a transparent approach appears to be effective. There is a stable staff team to promote continuity for the service users. A new care planning system is being implemented. The care plan is clearly a working document, which is being regularly reviewed. Once complete, the care plans in place are a good working examples of meeting individual and changing needs. All service users are supported within the Care Programme Approach framework and frequent reviews occur to ensure changing needs are continuously assessed and reviewed. A number of service users access external resources such as college, part time paid and voluntary work. There is a sound system for the provision of training and many training courses are currently available and are being attended by the staff team. All staff members have clear defined roles and responsibilities ensuring that the home functions smoothly. Service users expressed that they were happy with the systems and the management and staff within the home. Mandatory training is occurring in January 2006. Following a discussion with a service user that has recently moved into the home it is clear that there is a comprehensive referrals process including trial visits to the home. The service user was able to describe the process fully and felt that at all stages he was informed and aware of the information.

What has improved since the last inspection?

Following a service user moving into the house, new bedroom furniture has been arranged and chosen by a service user for his new bedroom, including redecoration. The hallway has also been painted. A new mini bus has also been purchased by the company, which will support the service users in accessing trips. Service user meetings have recommenced, although there is a need for these to be more frequent and structured. New induction paper work is in place which links to all required training standards and is being implemented for new staff. Improvements are also planed for the office space. Following the last inspection the deputy manager has commenced her Registered Managers Award.

What the care home could do better:

A number of areas have been identified as requiring further development. The inspection report must be on display and available to all service users, the accident and incident recording book must be maintained confidentially. An annual redecoration plan must be devised ensuring clear action and planning occurs to revamp and maintain the current environment throughout the year. There is a need for the company to ensure that they have requested a health declaration from all new employee`s to determine their fitness. Health and safety systems implemented following the last inspection must be monitored and reviewed and accurately completed in all instances, this includes, hot water checking, fridge and freezer temperatures, core foods temperatures, labelling of food items and correct storage. All electric appliances must be Portable Electrical Tested. Boxes that are a fire hazard in the upstairs hallway must be removed and all doors only held open by means recommended by the fire authority. Care plans must be fully completed and implemented for all service users, ensuring that the system in place is being reviewed, monitored and actioned by the management of the home. Care plans must also specify the delivery of care and what actual care needs the service users require. The staff at the home must ensure that a balanced focus is maintained with the medical modelof working as well as the inclusion of a social model to ensure all needs are being met.

CARE HOME ADULTS 18-65 Windsor House 8 Windsor Close Stevenage Herts SG2 8UD Lead Inspector Louise Bushell Unannounced Inspection 12th December 2005 10:00 Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 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 House DS0000062311.V270771.R01.S.doc Version 5.0 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 Adults 18-65. 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 House DS0000062311.V270771.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Windsor House Address 8 Windsor Close Stevenage Herts SG2 8UD 01438 813915 01438 813915 winnett@psycare.co.uk 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) Psycare Hostels Russell Fletcher Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th May 2005 Brief Description of the Service: Psycare Hostels limited operates Windsor House. It is a Psychiatric Aftercare Hostel / Personal Care Home focusing on providing, psychological, emotional and practical support to 3 male persons with enduring mental health disorders. Windsor House (cluster home) is a three bed home situated within 100 metres from its sister home Windsor House (core Home). The primary function of the cluster home is to compliment the rehabilitation programme commenced in the core home, providing a stepping stone into the community whilst working on the final stages of independent living. All service users living within Windsor House are able to access staff resources and support 24 hours a day. The home consists of three bedrooms and a communal bathroom on the 1st floor, a communal lounge and dinning room, kitchen, and down stairs toilet facilities on the ground floor. The home has a 24 hour pager system linked to the main core home. The home is situated down a lane with no through access to the public with ample parking facilities within a quite residential area. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the year for Windsor House, taking place mid morning through to the afternoon. This inspection focused only on the remaining core standards required to be inspected and reviewed the progress of the requirements and recommendations made following the last inspection. This inspection was completed in conjunction with Winnett Cottage, which is the core home available for service users prior to moving into Windsor House. This inspection aimed to seek the views of both service users residing at Windsor House and Winnett Cottage. The inspection process involved group and individual discussions with staff and service users. Time was also spent discussing and reviewing with the deputy manager, documentation and internal management systems. Currently the registered manager is completing her registered managers award. Where information has remained the same following the last report, reference will be made to the reader to see the previous report. What the service does well: Clear policies and procedures are in place that are well organised, maintained and accessible to all. All staff have recently received and completed their annual appraisal. The deputy manager has commenced her Registered Managers Award. The atmosphere throughout the inspection was calm and friendly, promoting a good relationship between staff and service users. Staff spoken with during the inspection were complimentary of the management style within the home. The ethos of working openly, honestly and with a transparent approach appears to be effective. There is a stable staff team to promote continuity for the service users. A new care planning system is being implemented. The care plan is clearly a working document, which is being regularly reviewed. Once complete, the care plans in place are a good working examples of meeting individual and changing needs. All service users are supported within the Care Programme Approach framework and frequent reviews occur to ensure changing needs are continuously assessed and reviewed. A number of service users access external resources such as college, part time paid and voluntary work. There is a sound system for the provision of training and many training courses are currently available and are being attended by the staff team. All staff members have clear defined roles and responsibilities ensuring that the home functions smoothly. Service users expressed that they were happy with the systems and the management and staff within the home. Mandatory training is occurring in January 2006. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 6 Following a discussion with a service user that has recently moved into the home it is clear that there is a comprehensive referrals process including trial visits to the home. The service user was able to describe the process fully and felt that at all stages he was informed and aware of the information. What has improved since the last inspection? What they could do better: A number of areas have been identified as requiring further development. The inspection report must be on display and available to all service users, the accident and incident recording book must be maintained confidentially. An annual redecoration plan must be devised ensuring clear action and planning occurs to revamp and maintain the current environment throughout the year. There is a need for the company to ensure that they have requested a health declaration from all new employee’s to determine their fitness. Health and safety systems implemented following the last inspection must be monitored and reviewed and accurately completed in all instances, this includes, hot water checking, fridge and freezer temperatures, core foods temperatures, labelling of food items and correct storage. All electric appliances must be Portable Electrical Tested. Boxes that are a fire hazard in the upstairs hallway must be removed and all doors only held open by means recommended by the fire authority. Care plans must be fully completed and implemented for all service users, ensuring that the system in place is being reviewed, monitored and actioned by the management of the home. Care plans must also specify the delivery of care and what actual care needs the service users require. The staff at the home must ensure that a balanced focus is maintained with the medical model Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 7 of working as well as the inclusion of a social model to ensure all needs are being met. 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. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 1 Service users would benefit from a copy of the previous inspection report being on display, thus to provide suitable information on the progress of the home and its required actions. EVIDENCE: A comprehensive Statement of Purpose is held within the home and all current and prospective service users are provided with a copy. The Statement contains information for the service user to make an informed choice about where to live. The content is suitable to meet individual needs. Feedback was directly sought from a service user who was currently on a trail period. Positive comments were received regarding the process of admission and the trail visits that had occurred to the home. The service user commented that he had all the information that was required for him to make an informed choice over where to live. A number of service users feed back that they were not aware of the inspection report that was produced following a visit from an inspector from CSCI. The home must ensure that this document is on display and available to all service users, encouraging and enhancing the availability of information regarding the home and actively empowering the service users to have information and choices in about where they live. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 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 the following standard(s): 6, 8 & 9 Care plans must be fully operational to ensure that individual needs, goals and changes are being identified, reviewed and monitored. Service users are appropriately supported to take part in an independent lifestyle, empowering them to manage person risks. Service users are provided and enabled to participate in all aspects of life, encouraging user involvement and selfadvocacy. EVIDENCE: The registered manager and staff team develops and agrees with each service user an individual Plan, which includes treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. All plans are service user focused and are aimed at increasing service user motivation and participation into community living. Staff are currently adapting and implementing a new care planning system. The care plan is clearly a working document, which is being regularly reviewed. Once complete, the care plans in place are a good working example of meeting individual and changing needs. It must be noted that following the last inspection in May 2005, progress with these service user focused plans has been slow and there is a need for the s provided to each service user, especially as the focus of the Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 11 units are to increase independent living skill, it is paramount that specific care and support needs are defined to monitor progress trends. Staff must implement the full generic system to ensure sound monitoring and management can occur. Plans must be reviewed as defined by the care plan at a minimum of twice yearly. Plans are required to be owned by the service user and therefore signed where possible. It must be noted that whilst some care plans were reasonably up to date and completed that many others still required work and further development. It is recommended that as part of the supervision process that the supervisor and supervisee discuss the requirements of each service users file and complete a detailed action plan to be reviewed at each supervision to monitor progress. Service user plans must also determine the level of support and specific support that is to be provided. All service users are supported within the Care Programme Approach framework and frequent reviews occur to ensure changing needs are continuously assessed and reviewed. Staff support all service users to take reasonable risks as part of independent living lifestyles. Those observed covered areas of risk such as deterioration of mental health state, violence to self and others, sleep disturbances, inappropriate sexual behaviour, self-neglect and physical health and absconding. Risk assessment completion is ongoing. Service users confirmed that they are enabled and supported in making choices within their lives and were aware of their individual care plans. One service user discussed the involvement that he had had in the formulation of the plan. Service user meetings do occur, direct feedback from a number of service users was rather mixed, concerning the aims and objectives of these meetings and their value. There is a need to ensure that these meetings are service user focused, that they are structured and occur at intervals appropriate to meet current needs for all. Where issues have been identified at a service user meeting, clear actions are to be noted to ensure that resolution can be gained. All service users complete a quality assurance questionnaire. Feedback determined that they found this useful as long as actions were taken following completion. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 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 the following standard(s): 14 & 15 Service users are encouraged and supported to take part in appropriate leisure activities, developing an independent lifestyle. Appropriate relationships are supported, empowering and encouraging integration into community living. EVIDENCE: Direct feedback was sought from the service users regarding the access to leisure facilities. In the garden of the cluster home, being Winnett Cottage all service users have access to a large well-maintained garden. A large shed / garage is also available which contains a selection of weight equipment and a pool table. Service users are encouraged to lead an independent life style and support is provided individually as required. Some service users work part time or on a voluntary basis, whilst some are enrolling and attending college. Leisure activities are not structured as many service users seek and engage in external facilities that provide leisure. Where a need is identified for appropriate support to be given then this is done so on an individual basis. Staff and service users have attending numerous places as small groups as apposed to group holidays. Feedback determined that the majority thought this was a positive experience and enjoyed them. Service users are encouraged at all times to live and develop independent living skills and life Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 13 styles. The company have recently purchased a number of new vehicles for the service and Windsor House will be able to have the use of a mini bus at all times. Drivers are also available to support in the facilitation of trips. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 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 the following standard(s): Standards not inspected on this occasion. Please refer to previous report for details. EVIDENCE: Standards not inspected on this occasion. Please refer to previous report for details. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 15 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 the following standard(s): Standards not inspected on this occasion. Please refer to previous report for details. EVIDENCE: Standards not inspected on this occasion. Please refer to previous report for details. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 16 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 the following standard(s): 24, 25, 26, 29 & 30 Service users are able to access a homely clean environment, encouraging and empowering them to develop independent living skills with the aim to move on to independent community living. Redecoration and renewal plans are required in order to ensure that the current environment remains homely. EVIDENCE: Windsor House presents as a family unit. Where home life is encouraged and integrated into daily living. Each service user has private space, which is individually decorated to each persona taste and character. Feedback from a service user currently on a trail period to the home, determined that they are offered the choice of the room to be repainted and furnished to meet individual need and preferences. A relaxed feel is present in all communal space, service users also feedback that they feel relaxed in the environment provided. The service users are encouraged to develop independent living skills and this includes laundry and general domestic chores. The service users purchase their own food and are provided with a weekly budget to purchase items of their own choice. Appropriate support is offered as required. At the time of inspection the environment was clean and hygienic. The service users complete most of the domestic chores in the house on a rota basis. It was well presented and homely at the time of the inspection. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 17 Bathing facilities are provided in sufficient numbers to meet individual needs. A redecoration and renewal action plan must be completed to ensure that communal areas are continuously upgraded. Recently the hallway area has been repainted. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 18 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 36 Staffing files contained all of the required information and suitable checks on all staff, thus ensuring the safety of the service users. The application form requires upgrading to ensure that each applicant makes a declaration of good health. EVIDENCE: Evidence of a number of staffing files determined that suitable reference and CRB checks have been made on all staff employed. Each file contained all of the required information. A suitable recruitment and selection procedure and policy is in place. Application forms are in place and are detailed and well designed, however there is a need for this to include a declaration of good health. Discussions took place with a member of staff that had been newly recruited following the last inspection. Positive feedback was provided with regards to the new induction training and the mandatory training that is arranged for January 2006, this includes, Food Hygiene, First Aid, Infection Control, Manual Handling, Health & Safety and Fire Safety. The member of staff discussed in full application process, including applying for her CRB. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 19 Staff have all received their annual appraisals and there is now a need for structured, regular, recorded supervision sessions to occur. The deputy manager has recently commenced her Registered Managers Award. Please see previous report for evidence found relating to the other standards inspected. With reference to supervision and care planning please refer to standard 9. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 20 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 41, 42 & 43 Areas of health and safety require reviewing and monitoring to ensure the ongoing safety of all service users is maintained in all aspects. EVIDENCE: Following the last inspection a number of new monitoring and recording systems were implemented to ensure that specific requirements under the Health and Safety and Food Hygiene legislation was being adhered to fully. On this inspection the systems were still in place, however they had not been completed with records showing more gaps than entries and in some instances had not been completed for the new month of December. The systems include, taking the core food temperatures of cooked foods – i.e. meat, the daily fridge and freezer temperatures, none labelling of food items in the fridge so date of opening was not clear to all. A system of recording the temperature of the delivery of meat had been implemented but following a few weeks of implementation this had not been completed since. There is a need for the Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 21 systems implemented to be completed by all staff. Whilst service users can be encouraged and empowered to complete these tasks the role and the responsibility must be lay with the staff. Current Portable Appliance Testing result could not be located on the day of the inspection, confirmation must be provided of completion of all appliances. An audit of the home must to be completed and this must include the visual checking of all sockets. The plug socket on the up stairs hallway requires fixing appropriately. An accident and incident book is in place, however there is a need for the home to ensure that all entries are made in accordance with the Data Protection Act 1998 and the appropriate slips completed torn out and filed separately. Please refer to the previous inspection report for information regarding the remaining standards. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 22 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 2 X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 X X 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 X 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Windsor House Score X X X X Standard No 37 38 39 40 41 42 43 Score X X X X 3 2 3 DS0000062311.V270771.R01.S.doc Version 5.0 Page 23 Yes 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 YA6 Regulation 15 (2) (a) & (b) Requirement The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. (This requirement has been carried forward from the previous two inspection, non compliance may result in enforcement action being taken). The registered manager must ensure that a copy of the inspection report is available for service users at all times. The registered manager must ensure that; • Fridge and freezer temperatures are recorded daily. • All appliances must be Portable Appliance Tested with evidence available. Timescale for action 31/03/06 2. YA1 17 (2) 29/01/06 3. YA32 13 (4) (c) 15/02/06 Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 24 • • • Core food temperatures to be recorded. Foods must be appropriately labelled once opened in the fridge and stored accordingly. The accident book and entries must be stored confidentially. 31/03/06 4. YA34 19 (5) (c) 5. YA24 13 (4) (c) Recruitment procedures must include a statement of health declaration from each employee to determine their fitness. A redecoration audit / plan to be completed detailing all works required with anticipated dates for completion for the forth coming year. 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA36YA9 Good Practice Recommendations It is recommended that all staff receive a supervision session that fully actions all outstanding works required in order to ensure all service user files and plans are up to date and are using the companies generic care planning tool. Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire 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 Windsor House DS0000062311.V270771.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!