Inspection on 02/12/08 for Windsor House

This inspection was carried out on 2nd December 2008.

CSCI found this care home to be providing an Adequate service.

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 12 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 19/12/07

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 30/01/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Windsor House 9 Cabbell Road Cromer Norfolk NR27 9HU     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Ruth Hannent     Date: 0 2 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 29 Information about the care home Name of care home: Address: Windsor House 9 Cabbell Road Cromer Norfolk NR27 9HU 01263511438 01263511141 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Provider/Manager Type of registration: Number of places registered: Mrs Sarah Jeans,Mr Robert Jeans care home 10 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: Ten (10) people with a Learning Disability may be accommodated. Date of last inspection Brief description of the care home 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. 10 Over 65 0 Care Homes for Adults (18-65 years) Page 4 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Individual needs and choices Lifestyle Personal and healthcare support peterchart Concerns, complaints and protection Environment Staffing Conduct and management of the home Poor Adequate Good Excellent How we did our inspection: The inspection was carried out using the Annual Quality Assurance Assessment completed by the Manager prior to this visit. Notifications since the last inspection have not been received. These inform of us of any changes in the service and as there has been no changes none were expected. No complaints have been sent and no comment from any resident or relatives since the last inspection. A site visit to the home took place on the 2nd December 2008 and lasted for 4 hours. Care Homes for Adults (18-65 years) Page 5 of 29 Care Homes for Adults (18-65 years) Page 6 of 29 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Adults (18-65 years) Page 7 of 29 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 8 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home should assess fully the needs of a potential resident prior to admission to ensure the needs can be met appropriately. Evidence: The manager carries out an assessment of need for any prospective resident. According to the Annual Quality Assurance Assessment (AQAA) the manager states she will not accept anyone to the home if she feels their needs cannot be met or if the residents already living at the home feel the person would be unsuitable. The home has not had any new residents since the last inspection and has only 6 residents living at Windsor House at present. Care Homes for Adults (18-65 years) Page 9 of 29 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents do have a care plan that is personalised but may be further improved in picture format for those unable to read. Residents are encourage to make the decisions about their own lives. Residents are consulted with over decisions about the home. Risks are identified and assessments written with the residents. Residents understand confidentiality and know information about them will be treated correctly. Evidence: The care plans are written for each residents and locked in a sideboard in the dining room of the house. On asking to see the care plans, two residents were approached to Care Homes for Adults (18-65 years) Page 10 of 29 Evidence: see if they would give their permission for us to look at their own care plans and also share with us the information written. Both gave details of how the care plan works and how they, themselves take an active part in tailoring the care plan to meet their own personal/health/social needs. Approximately a year ago the manager added a much more friendly style of care plan that is easier to read and in suitable print and colour to make them easier to understand and more interesting. To further improve this style some picture clues may also benefit the residents who are unable to read and could be developed in the future. There was no doubt that residents are empowered to have their say and take decisions about what they would like to do with their lives. One residents talked to us about her very busy life with a small job to going swimming and line dancing. Another talked of the recent pop concert attended. There was a small concern about residents who do not communicate verbally and show what they require through behaviour that is not always appropriate and noted on the day of this visit was the one person left for very long periods of time with only songs on the C.D. player to entertain and a book to flick through. On discussing this further with the manager this person is about to get some one to one hours from the independent living support that will help the Windsor House staff team recognise this persons needs. The home is run as a large family unit with people coming and going at different times of the day. The duties in the home are shared and residents are encouraged to be involved in the decisions for the home such as what shall we have for tea to, where shall we go Christmas shopping. (This was planned on the day of this inspection with residents wanting the inspection completed so the manager could take them out). Within the two care plans looked at were clear risk assessments for the individual. One of the residents spoken to talked of her visit to the local cafe but that if she goes anywhere else she goes with a staff member as she is at risk. She also knows that these risks are written in the care plan. Two of the residents are going through a process of checking out their ability to go out to local areas alone with one to one time with the supported living organisation. Residents on a number of occasions talked about confidentiality and that they understood what it meant. On a couple of occasions the manager asked politely if they would go to the other room and each time they understood it was to do with confidentiality. Care Homes for Adults (18-65 years) Page 11 of 29 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents are encouraged to take part in activities that suit them. The home is working towards residents being included in the local community. Residents routines and daily activities are respected and supported. Meals are offered with choice but intake and balanced daily meals should be recorded to ensure a healthy diet is eaten. Evidence: The AQAA gave details of how the residents lifestyles are unique to them. The two residents spoken to and who shared their care plan with us gave clear pictures of the different ways they are developing skills. We are being helped with skills on how to Care Homes for Adults (18-65 years) Page 12 of 29 Evidence: cross the road safely, I have a job helping at a centre where I make teas, coffees and wash up. Another resident who has one to one time has just been offered a course on the computer held in the local library. The professional organising this, called the home to plan the date during this inspection visit and the conversation was overheard. Events and trips out are regularly planned. One resident swims every week, another visits the little cafe at the back of the home, two go out to a day centre and one to one time for any activity is offered to the others. The home have an annual visit to Butlins in Skegness in the summer. A recent concert for Boys Zone at Blickling Hall was planned for a resident who is a big fan. On the day of this inspection visit two residents were waiting to go off to Wroxham to buy their Christmas shopping. On the day of this visit the home prepared a shepherds pie for the main evening meal to be shared when everyone had returned from their day at various places. At lunch time the two residents who were able, made themselves a sandwich as they were planning a MacDonalds later in the day. The larder door is not locked and the residents who are able can help themselves to what ever they wish. One resident is having dietary problems at the moment and rushed to the front door on the arrival of the post as she was expecting a letter from a dietician. Considering there was some concern over the eating and weight there was little recorded of the concerns. Scanty notes in the diary on some days of what food had or had not been eaten and only a record of the residents weight on one date was noted.(6/11/08). Care Homes for Adults (18-65 years) Page 13 of 29 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents do receive personal care support when they prefer and when required. The residents are supported by professionals to care for their health needs. Some medication procedures could be improved to ensure safe practice occurs when managing medication. Evidence: Some of the residents at Windsor House need help with personal care which is carried out in the privacy of their own room. With the home being a smaller unit, (6) residents at present, the support is available at any time of the day or night. Everyone has their own clothing, hairstyles and jewellery. Each one has a key worker who has built up a support of care that is suitable for the resident they are responsible for. The AQAA tells us of the healthcare support that is offered by the local GP practice. Each resident now has a health check annually. A local dentist and optician are visited by the residents annually and a chiropodist calls six weekly. One resident talked of Care Homes for Adults (18-65 years) Page 14 of 29 Evidence: support required to manage phobias and how the home staff and local medical practices have been helping. The recording of the good support offered for both personal and health care is not always recorded thoroughly and needs to be improved to ensure good practice is recorded appropriately. In the basement of the home the medication is stored within a locked cupboard under the stairs. Within the cupboard is a locked metal box that could be used for controlled drugs until a proper purpose drugs cabinet could be purchased if the need for a controlled drug is required. There is not a small fridge for medication to date but is to be purchased by the manager. The medication is supplied by Boots in a blister pack system that is delivered and old packs taken away monthly. The medication administration charts appeared completed fully and although the drugs charts did not show a residents photograph there is one on the care plan files to identify who is who. There is a returns book for all returned medication but this did not appear to have been completed for a number of months. An audit trail for all medication must have good record keeping to safeguard residents. Care Homes for Adults (18-65 years) Page 15 of 29 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some residents do understand the complaints procedures but others need help in understanding. Residents are protected from abuse and neglect. Evidence: The home has a complaints procedure that is in each residents care plan folder. They are printed in easy to understand English and two residents said they understood they can say when they are concerned or unhappy about something and it will be discussed and hopefully sorted. The home has no records of complaints and although no surveys have been received on this occasion, past inspections have quoted comments from the same family members of residents who live in Windsor House in a positive manner and no complaints necessary. The home could improve even further their complaints procedure by using pictures for the residents who cannot read to ensure every resident fully understands how to complain if they need to. The home has a training programme listed and within that programme is listed the training on the protection of vulnerable adults. With only the manager on duty on the day of this visit there was not the opportunity to talk to staff about their understanding of protection of adults. The manager showed the records of staff recently recruited who were not allowed to commence employment until the POVA first has arrived and Care Homes for Adults (18-65 years) Page 16 of 29 Evidence: can only work with a supervisor until the induction is completed and the CRB has been received. Care Homes for Adults (18-65 years) Page 17 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The general environment for the residents is of a poor standard and need to be improved to make it homely, comfortable and safe. Evidence: Windsor House is a converted terrace house that has over the years had to be improved. There are rooms within the house that are in a poor condition and although the owner is working to improve these areas the environment is at present unsuitable in many areas. On the day of this visit we were shown around the home by the residents. The top floor (three flights of narrow winding stairs) is being converted into a flat for one of the residents. The bathroom is half completed, the living room is half completed, although now has an appropriate alarmed door as a fire exit that leads to next door and was a requirement on the last inspection. The bedroom where the resident is sleeping is in a poor, unsafe state. A booster aerial wire was trailing across the sink and a booster box is left exposed on the window ledge. Two electrical sockets are directly next to the hand wash basin by the skirting board and could easily be splashed. The hot water tap was tested and ran inconsistently hot and cold on three attempts. The plug would not work to release the water and it took a long time for the water to drain out. Care Homes for Adults (18-65 years) Page 18 of 29 Evidence: Three bedrooms were seen and all of them had curtains hanging off the rails. One bed had been stripped and exposed a stained mattress. Another room was being shared by two residents while one room was being re plastered. There were clothes and possessions scattered around. The one resident does not like covers on the duvet or pillow but the pillow looked stained and in need of washing. The shower room was unclean with stains on the toilet seat and in the bowl. The home did not have any unpleasant odours but many areas looked generally unclean. The linen cupboard was untidy and items appeared thrown on the shelves. There was no towel or paper towels in the bathroom to dry your hands on. The lounge at the front of the house is large and has brown carpet tiles for replacing as and when required. On the day of this visit there was a tile missing and dried food was on the floor by a chair where the resident was sitting. The kitchen and dining room appeared clean but on trying the hand sink for preparation of meals the taps did not work. This was the same for the recently, much improved laundry that has been completed retiled and refitted but has a sink that does not work. We discussed the environment with the owner and he is well aware of what needs to be improved and has areas such as the cellar office and laundry looking much better but with so many areas touched on but incomplete it gives the overall appearance of shabbiness. There has been requested in past inspection reports a need for a programme of the building and refurbishment work so the changes can be seen on paper and the improvements monitored. Care Homes for Adults (18-65 years) Page 19 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The staff does have staff in suitable numbers but needs to have more to relieve the manager to carry out her duties. The home does support the staff to gain a suitable qualification and to attend training to build the staff skills. The recruitment process is robust to ensure residents are cared for suitable people. Staff supervision needs to be improved to ensure residents benefit from staff who are supported correctly. Evidence: The home has only six residents at present although they are registered for ten. On the day of this visit there was the manager on duty with one other staff member. Unfortunately this person had to go home leaving only the manager on duty. Two residents were away for the day leaving four at the house. Two of these residents were waiting to go Christmas shopping and had to be delayed due to the inspection and the need for a relief staff member to come in and cover. The two returning residents come home from day care and two staff will then be on duty until the night when one waking Care Homes for Adults (18-65 years) Page 20 of 29 Evidence: staff member is on duty. The manager is having to cover many of the shifts herself while recruiting and inducting new staff members to ensure the home is suitable staffed. The manager showed the records of staff who are training or who have already received an NVQ 2 qualification. The assistant manager has also achieved her NVQ 3 (certificates seen) and is working towards her NVQ 4. Although there was not a staff member to talk to the records seen show support is offered to staff appropriately. Personnel files were looked at and the correct paperwork was seen that included two form of identification, two references, CRBs, applications and contracts. The training matrix is held on the computer for all staff training. The list of who had taken training in this year was seen. The most recent being the food hygiene training which was a requirement from a previous inspection. The manager talked of the Skills for Care induction that all staff are taken through. She stated that no staff member would be left unsupervised who had not completed the induction and had at least had the medication and first aid training. One area of training to be covered is the Mental Capacity Act training that would be of great help to the staff at this home The files showed that appraisals had started and some supervision had taken place but this was very adhoc and recent supervision with dates recorded had not taken place. Care Homes for Adults (18-65 years) Page 21 of 29 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed by a competent person but has no recognised qualification and is not registered with the commission. The monitoring of quality is not thorough and does not include all interested people. The home does not record all areas of health and safety to ensure residents and staff are safeguarded. Evidence: The manager of Windsor House has been in post for a few years. Although the aim by this manager was to carry out a recognised qualification, due for unforeseen circumstances this has not happened. This person is also not registered with the Commission as the manager. The home is now working with the assistant manager to support her in gaining her NVQ 4 so that she will then become the registered manager. The home needs to ensure that a registered manager is in place as soon as possible. Care Homes for Adults (18-65 years) Page 22 of 29 Evidence: The home does not have residents meetings but staff listen and talk to residents to gather their thoughts and choices about the running of the home and the support they require. The manager talked of the quality surveys carried out but again this was done informally and not with other stakeholders, professionals or visitors. As previously mentioned in this report to get a full picture and ensure all residents participate in any review surveys in picture form may be more suitable. Recording practices are not up to date. The supervision of staff was overdue. The Environmental Health Officers requirements have not been carried out and another inspection is due shortly. The fire records for testing alarms and emergency lighting were not up to date. The home had no records available to show the audit trail for residents finances and although the receipts for all spends were in the home and money was available for everyone the records were held elsewhere and should be available for inspection. (This was discussed with the owner who is happy to show the inspector if required and who will ensure the information is held in the home for future inspections). The residents spoken to know the money is available and that they can buy items they want to. The manager does ensure that staff are trained in all areas of health and safety and the records were noted on the managers computer and by certificates issued to staff who have completed the courses. As previously mentioned fire records were not up to date and the water system was difficult to test with many taps noted to not be working. To ensure all areas of health and safety are promoted and residents are protected, regular monitoring and recording as listed in standard 42 should be taking place. Care Homes for Adults (18-65 years) Page 23 of 29 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action 1 24 23 (2) b c The registered person must produce a time bound plan for ongoing care and maintenance of the premises. 31/03/2008 Care Homes for Adults (18-65 years) Page 24 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 24 23 The home must ensure that appropriate, robust furnishings and fittings are suitable for the residents accommodated. To offer residents a suitable and comfortable environment. 01/04/2009 2 24 23 The home must ensure that 01/02/2009 taps run correctly and at the correct temperature in all areas. (Repeated requirement) To ensure good infection control procedures are followed and that water runs at a safe temperature. 3 24 23 The home must ensure all areas of the home are safe to include wrongly placed electical sockets and trailing wires. The home must be safe for residents. 01/02/2009 Care Homes for Adults (18-65 years) Page 25 of 29 4 24 23 The home must provide a programme for building works and refurbishment to show areas completed. (Repeated requirement) The home must be comfortable and homely. 01/04/2009 5 26 23 The home must ensure the soft furnishings are suitable for the needs of the residents. Mattresses/duvets/pillows and curtains/fittings need replacing. 01/03/2009 6 33 18 The home should recruit enough staff to ensure the manager is not always part of the rota The home needs reports completed by the manager that cannot be done when carry out care duties. 01/03/2009 7 36 18 The staff should be 01/02/2009 supervised and meeting recorded at least 6 times per year. (repeat requirement) To ensure continuity and support is correct for the staff member to carry out their duties correctly. 8 37 9 The home must provide a registered manager who is qualified to carry out the position The home has been without a registered manager for a number of years. 01/06/2009 Care Homes for Adults (18-65 years) Page 26 of 29 9 39 24 The home must have a system in place to review and improve the care delivered To ensure the quality of the service is reviewed on a regular basis. 01/06/2009 10 41 26 The home must ensure all 01/03/2009 records for testing, servicing and maintaining are held and ready for inspection. To safeguard the residents and ensure the building is safely maintained. 11 41 17 The manager must have the 01/02/2009 full record of all transactions taken on behalf of the resident fully up to date and available for inspection (schedule 4) To ensure residents money is managed correctly and safely. 12 42 26 The provider must carry out 01/02/2009 regular checks in the home to ensure records are up to date and the service delivery is correct and safe. To ensure a monitoring process is in place to help protect the residents from poor practices. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 6 It is recommended that a picture care plan is produced for Page 27 of 29 Care Homes for Adults (18-65 years) residents unable to read. 2 3 4 17 22 24 Meals taken should be recorded to ensure a balanced diet is eaten regularly. Residents who are unable to read may benefit from the complaints procedure constructed in a picture format. The whole home needs to be cleaner and tidier to ensure the enviroment is appropriate for the vulnerable people who live there. The home should plan training for the staff on The Mental Capacity Act. 5 35 Care Homes for Adults (18-65 years) Page 28 of 29 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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