Inspection on 23/06/05 for Windsor House

This inspection was carried out on 23rd June 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Windsor House 01/05/07

Windsor House 12/09/06

Windsor House 09/05/06

Windsor House 24/11/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Windsor House 209 Wigan Road Standish Wigan WN6 0AE Lead Inspector Kath Smethurst Unannounced 23rd June 2005 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Windsor House Address 209 Wigan Road Standish Wigan WN6 0AE 01257 421325 Telephone number Fax number Email 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 Ghulam Haider Mrs E Bone CRH Care Home only 16 Category(ies) of OP Old Age (16) registration, with number PD(E) Physical disability over 65 (2) of places Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home is registered for a maximum of 16 service users to include:up to 16 service users in the category of OP (over 65 years of age) up to 2 service uers in the category of PD(E) 2. The service employ a suitably qualified and experienced manager who is registered by the CSCI by 27/2/05. 3. The Registered Person must produce, by 31/1/05, a programme of routine maintenance and renewal of fabric and decoration of the premises. This includes both internal and external decoration. 4. The Registered Person must ensure, by 27/2/05, that the Home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 5. The Registered Person must ensure that a varied range of activities is planned and implemented by 27/2/05. 6. The Registered Person must ensure that the Home is appropriate staffed at all times and that service users are met by the numbers and skill mix of the staff. Date of last inspection 18 October 2005 Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 5 Brief Description of the Service: Windsor House is a large detached property in Standish. The home is situated on the main road to Wigan and Standish town centres and is approximately five minutes drive from local amenities. The front of the home offers impressive views over fields and the countryside. Car parking is available at the front of the home, and there is a large well maintained garden at the rear of the premises. There are five double and six single bedrooms. There are no en-suite facilities but toilets and bathrooms are situated close to bedrooms. The home provides personal care and support for sixteen residents over the age of sixty five. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 10 am. It took place over six hours during the morning and afternoon. The pharmacist inspector visited the home on the 2 June 2005 and checked medication records. The inspector looked around some but not all of the home. Records were looked at and the inspector ate the meal served to residents at lunchtime. To get more information about the home the inspector spoke to six residents, one visitor, the manager and two staff. One of the resident’s relatives also wrote to the inspector with her views about the home. What the service does well: What has improved since the last inspection? The home is gradually being redecorated and a lot of new furniture has been bought. These improvements have made a big difference to the residents and the home now looks more welcoming and homely. Residents and a visitor said how pleased they were with the improvements made to the home. Good progress has been made by the manager to make sure that the things, which needed improving from the last inspection, have been done. Residents and relatives were pleased with how the new manager was running the home and said she was willing to listen and put things right when necessary. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 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. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4 Systems are in place to ensure assessments take place but improvements are needed to documentation to ensure all care needs are identified. The manager and staff demonstrated a high level of commitment to ensuring the needs of residents were being met. EVIDENCE: If possible the manager will visit prospective residents prior to admission at their home or hospital whether they are paying for themselves or the local authority funds their care. One visiting relative confirmed the manager had conducted an assessment of needs prior to the admission of her mother. Inspection of the records of the two most recent admissions showed a full assessment of care needs had been completed by social workers. While it is evident the manager conducts a thorough assessment this is not fully reflected in the homes own assessment documentation. Further development is needed to ensure more detailed information relating to residents care needs is recorded, in order to guide staff providing care. The manager said she was in the process of addressing this issue and was planning to introduce a new assessment format in the near future. The manager is advised to refer the Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 10 National Minimum Standards for Care Homes for Older People-Standard 3 to ensure all areas highlighted are covered. All residents spoken to felt their needs were being met. Relatives were also satisfied with the care given. One described the care as being “good” while another who contacted the CSCI in writing wrote, “my mother is well cared for physically and in general is in a better state than she was”. During the inspection staff were seen to be attentive to the needs of residents and knew what care was needed. The manager had identified where staff required training and had arranged training sessions for staff in different aspects of care such as moving and handling, first aid, medication and National Vocational Qualifications. Where it was identified that residents had specialist health needs, health care professionals were involved. For example general practitioners, district nurses and the continence advisor. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 Progress has been made in improving care plans but further development is needed, as some plans do not provide staff with sufficient information they need when delivering care. The health needs of residents are well met with evidence of good multi-disciplinary working taking place on a regular basis. The systems for the administration of medication have improved but some records did not accurately record handling of medication in the home. Personal support is offered in such a way as to promote residents privacy. EVIDENCE: The manager advised she was currently in the process of introducing new care plans for all residents. The manager explained that when she first appointed there was little or no information about residents care needs even those who had lived at the home for some time. This meant she had a great deal of work to undertake to improve the situation. Some progress has been made but further development is needed to ensure all aspects of health, personal and social care needs are identified and planned for. Four care plans were examined to find the level of information varied from care plan to care plan. For example, one residents care plan contained some Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 12 very good guidance for staff when providing care. The plan read, “staff need to give Mrs X time to express her needs” and at night “make sure she has her yellow torch”. However in others the information was basic and care plans were not complete. Some plans contained details of resident’s weights others did not, comprehensive information about physical and social needs was not available in all plans. The manager advised monthly reviews were undertaken but there was no written evidence to support this. It was also noted that care plans had not been signed and agreed by residents and/or their representatives. All these areas need to be addressed. Despite the shortfalls daily entries in care notes had been made and gave a good indication of the care provided and residents well being. It was also noted that resident’s files were not particularly easy to read. The manager has already identified this as a problem and is planning to reorganise information into different sections of individual care plan files. Improvements to the system of completing and reviewing risk assessments are needed. While in the main risk assessments were completed there was no indication of some having been reviewed. It was also noted that a risk assessment had not been completed for one resident who required bedrails. Bedrails can be potentially hazardous therefore it is important their use is risk assessed and reviewed regularly to ensure they are appropriate, essential and safe. This was discussed with the manager who agreed to address this immediately. The health care needs of residents were being met. For example one relative was very complimentary of how staff had cared for her relative during an extended period of illness, and how this had helped her recovery. Individual care records inspected showed evidence of visits from General Practitioners, chiropodist, optician and district nurses. Progress has been made on improving the management of medication in the home but some improvements are needed. The medication storage was secure and orderly but some unwanted medication (an unlabelled eye drops) remained in the in-use medicines cupboard. All unwanted medication must be segregated prior to return to the pharmacy. The carer in charge on the day of the pharmacy inspection advised that medicines received by the home and unwanted medicines returned to the pharmacy, were recorded in dedicated books. These could not be located during the pharmacy inspection. Carers must be made aware of the location of these records to enable them to make entries when the manager is absent. Separate records of controlled drug handling were maintained. Medication Administration Records (MAR) were supplied by the pharmacy except for example when additional medication was provide mid-month then, care staff made hand written entries. Handwritten entries were not signed, Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 13 checked and independently countersigned. This is recommended to reduce the risk of errors. The MAR sheets were generally up to date but there were some blanks where administration or non-administration were not recorded. For example one resident was prescribed inhalers three times a day and twice a day, MAR entries were made once a day. The same resident was prescribed vitamins once a day but no entries had been made. Additionally the MAR included eye drops twice a day, the only supply was unlabelled and the carer believed they were discontinued, but this was not indicated. This needs to be addressed to ensure all records are accurate. None of the residents self-administer. Staff responsible for the administration of medication has undertaken training. Current guidance indicates “ the person administering medicine should sign the administration record immediately after the medicine has been given” this will help to ensure that entries are clear and unambiguous. There were some blanks in the administration records where administration or the reason for non-administration was not recorded, indicating the procedure is not always adhered to. The manager should ensure the procedure is strictly adhered to. Anecdotal evidence from residents indicated that staff respected their privacy and dignity. During the inspection staff were seen to treat service users with respect and consideration, were attentive to individual needs and were discreet when providing assistance. One relative who contacted the CSCI in writing gave an example of how the staffs approach had improved her mothers self esteem, she wrote, “ The way staff care for her has restored her dignity and self respect”. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 15 Visiting arrangements are good ensuring links between residents and their relatives and friends are maintained. Meals are good and the needs of residents are well catered for with a balanced and varied selection of food provided. EVIDENCE: The home has an open visiting policy. There are no restrictions on the time people visit and this was evident, with visitors observed during the whole of the period of the inspection. Further evidence was highlighted in the visitor’s book where entries showed residents friends and relatives visiting at different times during the day and evening. The only time restrictions would be imposed is when requested by residents. Anececdtal evidence from both residents and relatives indicated the manager and staff encouraged links to be maintained. A visitor spoken to confirmed she was always made to feel welcome by staff, while a relative who contacted the CSCI in writing wrote, “Whenever any member of the family has visited, or telephoned for information, we have been greeted in a friendly and courteous manner, made to feel welcome and given all the help we have asked for”. Further evidence of this was also observed, staff greeted visitors politely and took time to talk to them. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 15 A new cook has recently been employed and new menus have been developed. The menus were inspected and were found to be well balanced and varied. A choice is offered at every meal. Written evidence of the choices and alternatives residents have is maintained. Breakfast is served on a flexible basis, the main meal being served at lunchtime, and a lighter tea being served at around 4 p.m. Drinks and snacks are provided throughout the day. Discussion with the cook indicated the food budget was sufficient and only good quality produce is used. Meat, fruit and vegetables are all fresh and supplied by local traders. A plentiful supply of fruit and vegetables was observed in the kitchen. Meals are home cooked and the use of convenience foods is limited. For example the cook had baked cakes for tea and was going to make a fresh strawberry pavlova for dessert the following day. A number of residents living in the home were spoken to and everyone who commented said the food was good. All expressed satisfaction with the quantity and quality of the meals provided. Residents also confirmed that if the meal was not to their liking an alternative was always made available. Evidence of which was observed when one resident asked for and given an alternative meal at lunchtime. The resident in question said she was very particular about the type of food she liked and often asked for different meal. She confirmed staff always accommodated her requests in this respect. The inspector sampled the food served at lunchtime. The meal consisted of hotpot and red cabbage followed by sponge and custard. The meal was well presented and tasted good and appeared to be enjoyed by the residents. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a satisfactory complaints system with some evidence that residents feel their views are listened to and acted upon. EVIDENCE: A complaints procedure is in place. Details of how to complain are contained in contracts, which each resident or their representative has a copy of. A system is in place for recording complaints. The homes complaints book was examined to find no complaints had been logged since the last inspection in October 2004. No formal complaints have been received by the CSCI. Anecdotal evidence from residents indicated they felt able to approach staff with any concerns and these would be taken seriously. None of the residents had made a complaint but all indicated they were aware of how to do so if the need arose. A visitor said that she had not had any major concerns but when a minor issue concerning her mother’s care had arisen this had been dealt with immediately and resolved to her satisfaction. The visitor was also very complimentary about the way the owner took an interest in the way the home was run. She said he regularly spoke to both her mother and herself to ask if they were happy with the care provided or if they had any complaints or concerns. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 24 and 26 A recent programme of decoration and refurbishment has resulted in significant improvements, providing residents with a clean, pleasant and comfortable environment. EVIDENCE: Since the owner purchased the home in December 2004 the standard of the environment has improved significantly. During the last inspection it had been identified that many areas of the home needed attention. The new owner has now addressed the requirements made. Residents and a visitor spoken to were delighted with the improvements made. Since the last inspection the outside of the building has been repainted. The hall, stairs and landing areas have been redecorated. New curtains have been purchased for the lounge and dining area. The lounge and dining area are due to be redecorated in the near future; following which new carpets will be fitted. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 18 The standard of the décor in bedrooms has also improved. New beds, carpets, bedding and curtains have been purchased and the majority of the rooms have been redecorated and new light fittings have been installed. Bedrooms are personalised with photographs and personal mementoes on display. Doors have now been fitted with locks that can be opened by staff in an emergency. Now the general environment is at an acceptable standard other areas can now be addressed as part of a planned programme of renewal and refurbishment. The following areas require attention; lockable storage needs to be provided in bedrooms; although functional some wardrobes, lockers and drawers are old and show signs of wear and tear and as such should be replaced. All areas of the home were clean and odour free. Residents and a visitor commented positively about the cleanliness of the home. Policies and procedures were in place with regard to infection control. Staff were provided with protective aprons and disposable gloves. Liquid soap and paper towels were provided near to hand washing facilities. Staff were observed to be maintaining good hygienic practices. All laundry is undertaken on site and residents spoken to had no complaints about the standard of laundry service provided. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29 Staffing levels are satisfactory ensuring consistency of care and recruitment procedures for staff are robust which ensures people living in the home are protected. EVIDENCE: On the day of inspection sufficient staff were on duty to meet residents care needs. Examination of staff rotas showed that when staff were on leave or off sick absences were covered. One member of staff covers the waking night shift, whilst one member of staff sleeps in. This was discussed with the manager in order to ascertain if this was adequate. The manager advised that as there were only ten residents staffing levels at night were sufficient, but would be increased if necessary. During the visit staff were observed to respond speedily to requests for assistance made by residents and they also spent time socialising with them. Staff spoken to said ratios were adequate, as did residents and a visitor. The staff files of four staff employed indicated that all necessary recruitment checks had been undertaken. All staff files examined contained: written application forms, 2 references, Criminal Records Bureau (CRB) check and verification of identification. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 35, and 38. The home is well managed resulting in a consistent and reliable service for the people using it. A satisfactory accounting system is in place, which ensures resident’s interests are protected. Health and safety practices are on the whole satisfactory but fire safety precautions were not being carried out at the required frequency which could put residents and staff at potential risk. EVIDENCE: The manager was appointed following the change of ownership of the home. It was clear from the previous inspection, where a large number of requirements had been made that improvements needed to be made. The manager has made good progress in addressing many of those requirements. She also has a good understanding of the areas, which the home still needs to improve upon. To do this she needs some dedicated time where she can concentrate wholly on particular tasks for example improving and updating care plans. This was discussed with the owner who agreed to arrange this. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 21 The manager is a registered nurse and has extensive experience of managing care homes for older people. Although she has considerable experience, she does not have a formal management qualification and has yet to commence the NVQ level IV award. The manager is aware she needs to complete the award to continue managing the home and was hoping to commence training in the near future. Staff spoken to all indicated that the manager provides clear leadership and direction. One member described the manager as being “ very supportive and approachable.” Residents who commented were all aware of whom to approach if they had a concern or problem. The Home looks after small amounts of resident’s personal allowances. Detailed records are held of all transactions. All monies held for safekeeping are kept individually. A record is kept of monies credited and debited and receipts were obtained for financial transactions. Secure facilities are provided for the safe keeping of money. In the main health and safety issues were satisfactory. Policies and procedures are in place and cover a range of topics linked to health and safety. Documentary evidence was available of staff having completed health and safety training including safe moving and handling techniques. Staff spoken to also confirmed this. Accidents had been recorded appropriately. Records examined showed evidence of regular inspections and maintenance checks of equipment and the building undertaken by external contractors, so ensuring the safety of both residents and staff. One area, which needs to be addressed, is in respect to fire safety records. The fire logbook was examined to find safety precautions were not being carried out at the required intervals. For example tests to the fire alarm and means of escape were not being completed weekly. It was also noted that staff had not completed a recent fire drill. These shortfalls need to be addressed to ensure the safety of both residents and staff. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 2 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 2 x x x 3 x x 2 Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 23 no 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. 2. Standard 3 7 Regulation 14 15 Requirement Assessments must cover all areas indicated in National Minimum Standard 3. Care plans must reflect full details of service users assessed needs and actions necessary to meet needs (see standard 3.3); care plans must be drawn up with and signed by service users or representative and be reviewed on a monthly basis. Risk assessments must be completed and regularly reviewed Medication records must be complete, clear, accurate and up to date All unwanted medication must be promptly segregated for disposal Residents must be provided with lockable storage space for medication, money and valuables with a key provided unless the reason for not doing so is explained in the care plan. The manager must register to undertake the NVQ level 4 registered managers award. To ensure the safety of both residents and staff fire safety tests and precautions imust be Timescale for action 30 August 2005 30 August 2005 3. 4. 5. 6. 7 9 9 24 13 & 15 13 13 12,13 & 23 31 July 2005 30 june 2005 30 June 2005 30 June 2005 7. 8. 31 38 9 17 & 23 30 August 2005 31 July 2005 Page 24 Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 carried out and at the required frequencies with the results recorded in the fire log. 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. 4. Refer to Standard 9 9 9 24 Good Practice Recommendations The medication policies and procedures should be available to trained staff. Hand written MAR entries should be signed, checked and countersigned. The manager should discuss the potential to label both the bottle and outer container e.g. for eye drops with the supplying pharmacisit. As part of the homes planned programme of refurbishment consideration should be given to purchasing new wardrobes, chest of drawers and lockers. Windsor House F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Turton Suite, Paragon Business Park, Chorley New Road, Horwich, Bolton, BL6 6HG. 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 F56 F06 S52654 Windsor House V230436 090605 Stage 4.doc Version 1.30 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!