Inspection on 19/12/07 for Windsor House

This inspection was carried out on 19th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Windsor House 22/06/09

Windsor House 02/12/08

Windsor House 05/02/07

Windsor House 09/05/06

Windsor House 01/10/05

Windsor House 12/04/05

Windsor House 23/11/04

Windsor House 30/07/04

Windsor House 19/05/04

Windsor House 19/11/03

Windsor House 07/10/03

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

CARE HOME ADULTS 18-65 Windsor House 9 Cabbell Road Cromer Norfolk NR27 9HU Lead Inspector Mrs Ginette Amis Unannounced Inspection 19th December 2007 11:30 Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 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 DS0000027290.V356871.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 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 DS0000027290.V356871.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windsor House Address 9 Cabbell Road Cromer Norfolk NR27 9HU 01263 511438 01263 511141 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) Mr Robert Jeans Mrs Sarah Jeans Not applicable Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Ten (10) people with a Learning Disability may be accommodated. Date of last inspection 5th February 2007 Brief Description of the Service: Windsor House is a care home providing personal care and accommodation for up to 10 adults with learning disabilities. The Registered Providers are Sarah and Robert Jeans. The present manager is Denise Appleton who is planning to make application to become the Registered Manager. The home is located very close to the sea in the coastal town of Cromer and is close to shops, pubs and all local amenities. Windsor House is a large Edwardian terraced property with accommodation on four floors. The property has been in a poor state of repair but the Proprietor is in the process of making some improvements in the home. Service users are accommodated on the first three floors. The weekly fee is between £295 and £360. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place from 11:30 in the morning till 16:15 in the afternoon of the 19th December 2007. Following a period of sick leave, the manager Ms Appleton had returned to full time work at Windsor House 6 weeks prior to this inspection. In the weeks immediately preceding her return, she had spent some time dealing with outstanding administration, including for example the preparation of a quality assurance system for use in the care home and a review of staff files. She stated her intention of re-applying to CSCI for registration as manager and recommencing work to become accredited at NVQ Level 4 in care management early in 2008. The Annual Quality Assurance Assessment was returned to CSCI by Ms Appleton on 20/06/07. Of the survey comment cards returned to CSCI in December 2007 one was from a Health Care professional, 3 were from members of the staff team and 2 were from relatives. All contained positive comments on the care home. None of the 9 residents returned comment cards but all were met with during the course of the inspection. The majority of residents were very happy to make a verbal contribution, offering their views on the care home, the management and staff group, their daily lives, relationships and preferred activities in and out of the care home. All of the residents spoken with made it clear they were content. The manager, her deputy and 3 other members of staff were met with during the course of the day. All helped to create a cheerful, relaxed atmosphere. One visiting relative said of the staff “everyone is kind” going on to commend their helpfulness at all times. The quality outcomes for Standards 1 –23 were virtually all met. This reflects the good relationship between the manager, staff and residents and an ethos of open, friendly supportiveness. Work commenced on care planning had been completed to a good standard and residents now felt they owned these documents. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 6 Unfortunately environmental standards failed to reflect the efforts made by manager and staff to raise the level of the service. Although the care home was generally clean and there had been some improvements made to the premises in the form of redecoration and some new furniture, yet more work remained to be done. The provider had failed to act on two important requirements set at the previous inspection. These were as a result repeated along with 3 other requirements, 2 of which attached to the premises the 3rd to the providers’ failure to inspect the premises regularly in line with Regulation 26. What the service does well: What has improved since the last inspection? The transformation of care plans into user-friendly documents that residents themselves contributed to and were fully aware of had been completed. Most now included a similarly styled form of risk assessment. Staff files had been reviewed and training needs identified. Staff supervision had got underway. All staff had been trained in the safe administration of medication. Plans were in progress to meet other outstanding training needs. The lounge dining room and kitchen had been redecorated and as smoking was no longer permitted the smell of cigarette smoke has ceased to be an issue. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 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 DS0000027290.V356871.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 4. Quality in this outcome area is good. Policies and procedures were in place at Windsor House that would assist any person considering going to live there in making an informed choice. The new guide to Windsor House once completed would be helpful to this process This judgement has been made using available evidence including a visit to this service. EVIDENCE: Preparation of a new service user guide though well advanced remained in progress. We, the Commission for Social Care Inspection (CSCI) inspected a draft copy that was colourful, written in larger print and composed in a style designed to be attractive to potential service users. It was recommended this new version of the Guide to Windsor House be brought into use as soon as possible. The manager stated in the Annual Quality Assurance Assessment (AQAA) that those people already living at Windsor House would be consulted over the possible admission of a new resident. In addition clear guidelines were described suggesting an appropriate admission procedure to be in place and that any prospective new resident would be given every opportunity to visit the care home and meet with existing residents and members of the staff team. As there had been no person admitted to the care home since the previous inspection of February 07, it was not possible to test if procedures had worked in practice to meet the recommendation made at the previous inspection for existing residents to be consulted. However, residents spoken with claimed they would have no reservations over making their views known. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. Quality in this outcome area is good. While some work still remained in progress improvements had been wholeheartedly assimilated into the culture of the care home. Residents felt their care plans belonged to them and reflected their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The files of 6 people living at Windsor House were examined. Residents were aware these files were their property but happy for us (CSCI) to see them. Some of the residents talked about their input to their care plans, demonstrating how these had been constructed with the manager in a collaborative manner. All had been signed by the persons concerned to indicate their agreement with the content of the care plans. New, clearer versions of risk assessments compiled with the residents help were being added as completed and it was evident that while this remained work in progress it was well underway. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. Residents enjoyed the warmth and friendship they found living at Windsor House, considering the manager and staff their friends as well as sources of support. The value placed on residents’ views and feelings by the manager and her team had enabled residents to develop their social skills and enjoy those opportunities for fulfilment available to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In the course of the inspection we (CSCI) were able to meet with all of the residents. Conversations with residents and observation of their interactions with the manager, members of the staff team and one another gave very clear indications that people living at Windsor House benefit from feeling part of a warm, sociable and generally relaxed household. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 12 When we (CSCI) arrived, a group of residents, guided by a member of staff were busy planning, then helping to prepare that day’s meals. It was obvious residents’ expected their views, likes and dislikes to be taken into account but listened to staff advice about the need for healthy balanced diets. A recommendation was made for the food hygiene certification for staff to be renewed, as planned, early in 2008. As the inspection fell close to Christmas residents spoke cheerfully about their preparations and what they were looking forwards to doing. Two members of staff who were off duty dropped in to deliver presents for residents and shopping done on their behalf, staying a while to socialise. The atmosphere was noticeably happy and relaxed. Residents spoke of how they usually enjoyed a good social life both at Windsor House and at the clubs and places they visited during the week. This reflected information in their care plans. One resident had been out for lunch with a family member that morning. Another resident held a part time post in the community and after coming home for lunch went out again to do more shopping in the town. Residents spoke of friendships made within the care home as well as those forged outside of it. Noting the cheerfulness of the atmosphere at Windsor House, we (CSCI) asked about possible fallings out, to which one resident responded “well yes sometimes some people fall out but we usually get it all straightened out again”. A resident’s visiting relative described the care home as being a “wonderfully friendly and happy home” and its’ staff group as “the most caring people you could hope to find anywhere”. Two residents who had been out all at day centres returned later in the afternoon and from their manner, in greeting members of staff appeared completely at ease and at home at Windsor House. We (CSCI) enquired about the proposed trip to Disneyland Paris, as noted in the previous inspection but as a result of the manager being on sick leave this had been postponed. However, on her return to work residents and staff had taken a week’s holiday at a holiday camp in Skegness. A mini bus and driver had been hired for the journey and the holiday had been a great success. Residents showed us (CSCI) their photographs and described their activities and the pleasure they had had during their stay in Skegness. The manager explained how, with residents’ mostly having their own individual agendas to follow, there was little call for a mini bus save for use on annual holidays. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 13 From the above observations we (CSCI) concluded that people living at Windsor House were content with their lifestyle and had the confidence to make the most of those opportunities for enjoyment available to them. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We (CSCI) noted that non of the residents currently living at Windsor House had been assessed as able to administer their own medication and those asked about this indicated they would not wish to. Medication in current use was safely stored and records showed this to have been appropriately administered. However the care home lacked a drugs refrigerator or special storage for controlled drugs. While neither was necessary at the time of the inspection as medication in stock was not of a type requiring such special storage, a recommendation was made for these facilities to be put in place in case of future need. All staff members had been trained in the administration of medication. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 15 A key-worker system had been introduced and residents were aware who their own key-worker was. The manager stated she wished to further develop this role over the coming year. Residents’ health care needs were fully outlined in their care plans with clear goals and agreed strategies for meeting them. A recommendation was made that where a potential area of concern, as set out in the residents’ file, did not apply, the record should state this was not applicable so as to avoid the possibility of confusion. All residents had access to local NHS services. The manager was aware of the limitations of the care home to cater for residents’ whose needs over time might come to require specialist or nursing care and of the procedures to be taken. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. Residents benefited from living in an open environment where their views and feelings were taken appropriate account of. Members of the staff team had been trained to protect the vulnerable adults in their care from any potential abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The file of each resident was found to contain a clearly laid out copy of the home’s complaints’ procedure. Residents asked about this said they would take any concern they might have first to their key worker or to the manager. All felt confident their worries would be immediately addressed. One visiting relative when asked about how concerns might be dealt with said “You can wonder in at any time, residents are always happy and cheerful – I’d recommend this home to anyone, the staff are so kind. If you’ve any problem you only have to ask, they always do their very best to sort things out. You can ring them and ask anything.” Staff have received externally verified training in the protection of vulnerable adults from abuse and were made familiar with the home’s policies and procedures to help ensure the safety of residents. All staff had been issued with the General Care Council Code of Conduct. There had been no concerns or complaints raised about the care home since the previous inspection. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28 and 30. Quality in this outcome area is poor. Although some improvements have been made further work must be undertaken by the providers to raise environmental standards. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was made immediately on arrival at Windsor House and parts of the care home were revisited later in the day. On the whole the house was found to be generally clean. Smoking was not permitted within the care home, one resident and any member of staff who still smoked making use of the small patio outside the dining room to do so. The bathroom on the first floor had been pleasantly appointed and was clean and in good condition. The dining room and kitchen were also clean and bright and appeared to indeed be the centre of the house. The front lounge had been redecorated and some new furniture provided. However, curtains had been pulled off their runners and left at ‘half mast’ and damage to the door surround, where a new frame had recently been fitted Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 18 remained to be made good. One arm-chair looked close to collapse. Some new carpets had been provided but carpets generally appeared of poor quality and were loose and crinkled in places. When we (CSCI) inspected some of the bedrooms it was evident that their occupants had been encouraged to personalise their rooms in ways they liked, but much of the furniture provided by the care home looked worn and of poor quality. One chest of draws had most of its’ draw fronts detached. Rooms that had previously been designed around double occupancy but were now single occupancy retained the second unused bed and dividing curtains. When the water temperature was tested at one of the sinks it was found to be very hot. The requirement for water temperature to be set at safe levels made at the previous inspection was as a result repeated. One resident occupied a room with a fire escape into the adjoining premises. The resident in occupancy did not consent for her room to be inspected but the manager was able to provide evidence in the form of a letter from the fire officer giving permission for this fire door to be locked from the Windsor House side. A requirement was made for a new risk assessment to be made of this area and its use. Risk assessments of the premises must be regularly updated in light of the changing abilities of residents, their advancing years and general use of the care home (eg if any resident should wish to make use of the laundry). The laundry, along with the manager’s office were sited in the basement and accessed by a steep staircase. No attempt had been made since the last inspection to improve the laundry room. The walls and ceiling of the laundry room remained unfinished, lacking any form of cladding or plaster over bricks and ceiling joists. There was no heating supplied to the laundry which, like the office, was exceptionally cold. There was a great deal of junk (empty boxes and other items) in the laundry and a second, at present unused office that was attributed to the unpacking of Christmas decorations. It was noted how this area had been similarly cluttered at the previous inspection. The requirement for the laundry to be improved, plastered through or similarly finished so that brickwork is concealed, suitable flooring laid and cleared of clutter was repeated. In addition this area must be properly heated in winter. The manager stated that some improvements to the heating system were planned for the home. The providers must be aware that members of staff cannot be expected to work in so intolerably low temperatures as exist in the basement at present and must address this in conjunction with making other improvements. The manager has re - introduced a maintenance book to be used in conjunction with inspection of the premises – but see section on Management and Administration. The provider must adopted a time bound, planned approach to maintenance and renewal and the general condition of the home and its furnishings. Requirement Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. Improvements have been initiated which support optimism that in future outcomes will be good but there has been insufficient time since their introduction in which to judge their value. The commitment of the manager and staff to enabling residents to enjoy life at Windsor House was not in doubt but the small size of the staff team remained a cause for some concern. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From observation of their interactions with the people living at Windsor House and with one another it was evident to us (CSCI) that the staff team has a strong, enabling relationship with the residents. The ethos of the care home appeared positive, friendly and open, and essentially good humoured and caring. The manager and deputy displayed a commitment to residents in their care and other members of the team spoken with during the inspection gave indication of how closely they identified with residents. Each of the 4 members of staff who returned the CSCI staff survey stressed how important they considered the provision of a warm, loving home where individuals were treated as such, their views and feelings respected. The 2 relatives who returned surveys both stated how they “could not ask for better from all staff”. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 20 At the time of the inspection the care home was adequately staffed. The manager who had returned to work full time following her sick leave only 6 weeks prior to the date of the inspection was working in a managerial capacity, not as a member of the care team. However given the small size of the care team, 9 persons in all, the potential for running into a crisis should there be an epidemic of flue for example remained great. The manager was strongly recommended to build up a bank of relief staff capable of filling gaps caused by unplanned staff leave. Staff files had been reviewed since the manager’s return to work and now contained all relevant information as required. These files contained evidence of training undertaken. There were 5 members of the care team who had gained NVQ level 2 accreditation and 3 more were currently working towards this. No new staff had been appointed recently but the manager was confident that procedures would be appropriately applied in future. Staff training needs had been reviewed and arrangements made to renew or meet training needs as necessary. It was evident how improvements in systems had been initiated but that given the short amount of time the manager had had at her disposal since her return to work, these systems remained in their infancy and had yet to be tested. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The return of the appointed manager to full time employment at Windsor House gave cause for cautious optimism. Her concern for the welfare of the residents of Windsor House was made very apparent during the course of the inspection. The manager hoped to reapply for registration with CSCI early in 2008 and said she was also arranging to recommence accreditation in NVQ Level 4 Care Management. Prior to returning to full time employment at the care home she has devoted some time to reviewing staff files, updating policies and procedures and devising a new quality assurance system for Windsor House. As required at the previous inspection, the manager had begun to introduce a formal system of staff supervision. Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 22 Information contained within the AQAA denoted that administrative procedures were gradually being brought up to date though in the manager’s own words there “is still work to do”. Without doubting her sincerity or commitment to the task it had to be recognised that unless the staff team increased in number, there would remain a danger of events taking precedence over the need to attend adequately to purely managerial tasks. Fire fighting equipment and fire detection systems were last reviewed and serviced 31/1/07. Windsor House did not have an on call system. But see need for risk assessment Environmental Section. While a policy was in place for infection control, see too repeated requirement re laundry and heating system. A health and safety book was in place but we (CSCI) have not assessed standards of health and safety beyond those already noted. No evidence was found of the providers having complied with Regulation 26 Care Home Regulations 2001. A requirement was made for the provider to commence making visits to Windsor House in line with Regulation 26 without delay and to send monthly reports to CSCI and to the manager as detailed by this regulation. Windsor House DS0000027290.V356871.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 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 Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 2 26 1 27 X 28 2 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 3 2 X X 3 X Windsor House DS0000027290.V356871.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 YA24 Regulation 13 (4) Requirement The registered person must that hot water taps in residents’ rooms are set at safe temperature levels. Repeat Requirement The registered person must complete a risk assessment in relation to the use of the bedroom with a fire door connecting to a neighbouring property and ensure that all such risk assessments are reviewed regularly. 3. YA30 23 (2)d 16 (2)f The registered person must ensure that the laundry walls ceiling and floor are suitably covered, that clutter is cleared and the area made clean and appropriate for use as a laundry by residents and staff. Repeat Requirement The registered person must ensure that all parts of the care home are adequately heated, including the laundry. 01/03/08 Timescale for action 31/03/08 2. YA24 13 (4) 14/02/08 4. YA30 23 (2) p 31/03/08 Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 25 5. YA39 26 6 YA24 23 (2) b c The registered person must 14/02/08 commence to inspect the care home once each month and complete a report on his findings and actions taken, submitting a copy to the manager and to CSCI in line with this regulation. The registered person must 31/03/08 produce a time bound plan for ongoing care and maintenance of the premises. 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 YA1 YA17 YA18 Good Practice Recommendations The new style guide to Windsor House should be brought into use as soon as possible. Plans to ensure all members of staff should all have up to date food hygiene certificates should be implemented It would be good practice to write ‘not applicable’ in a resident’s file where a particular type of need does not apply to that resident, rather than leaving sections blank. A drugs fridge and controlled drugs cabinet should be made available in case of future need. The manager should seek to recruit relief staff in sufficient numbers to call on in times of crisis or arrange to use an agency to supply additional staff cover. 4. 5 YA19 YA33 Windsor House DS0000027290.V356871.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 House DS0000027290.V356871.R01.S.doc Version 5.2 Page 27 - 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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