Inspection on 24/11/05 for Windsor House

This inspection was carried out on 24th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

Other inspections for this house

Windsor House 01/05/07

Windsor House 12/09/06

Windsor House 09/05/06

Windsor House 23/06/05

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 Windsor House 209 Wigan Road Standish Wigan WN6 0AE Lead Inspector Kath Smethurst Unannounced Inspection 24th November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000062654.V258301.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Windsor House Address Windsor House 209 Wigan Road Standish Wigan WN6 0AE 01257 421325 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 Ghulam Haider Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16), Physical disability over 65 years of age (2) of places Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 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 (Older People over 65 years of age) up to 2 service users in the category of PD(E) (Physical Disability over 65 years of age) The service should employ a suitably qualified and experienced Manager who is registered with the Comission for Social Care Inspection. The Registered Person must ensure that a varied range of activities is planned and implemented by 1/8/05. 23rd June 2005 2. 3. Date of last inspection 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 DS0000062654.V258301.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The previous inspection took place on the 23 June 2005. This inspection was unannounced and started at 10 am. It took place over five hours during the morning and afternoon. The inspector looked around some but not all of the home, checked care plans and some records. To get more information about the home the inspector spoke to four residents, one visitor, the owner, the manager and two staff. What the service does well: What has improved since the last inspection? What they could do better: Assessments and care plans need to have more written information so that people reading them have a clear picture of each person needs help with. There is also a need to make sure residents are involved in the planning and review of their care. The home needs to improve upon how often risk assessments relating to moving people safely and nutrition are completed and reviewed regularly. This must be addressed quickly to ensure any potential risks to resident’s health and safety is known and monitored. The range of leisure pursuits inside and outside provided for residents need to be increased, so residents have the opportunity to pursue their interests and hobbies and develop new ones. Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 6 Staff were uncertain about their responsibilities in the case of a suspicion or allegation of abuse and were unaware of vulnerable adults procedures. This needs to be addressed as this lack of understanding could potentially jeopardise any adult protection investigations. Not all staff had received training to do their jobs properly, nor had they all had 3 days training over the past year. More training is needed in how to move people safely, first aid, food hygiene and what to do in the event of a case of suspected abuse. 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 DS0000062654.V258301.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 3 Assessments take place but limited progress has been made to assessment documentation to ensure all care needs are identified prior to people moving into the home. EVIDENCE: The manager advised she visits prospective residents prior to admission whether they were paying for themselves or if the local authority was funding care. The manger said she had undertaken visits to the two most recently admitted residents to conduct an assessment of their needs. The care records of these two residents were examined. One resident had a social work assessment completed prior to admission. The second resident did not have full assessment information recorded. This situation was also seen at the last inspection visit when a requirement was made for action to be taken to ensure proper assessment documents be developed, so that a full assessment of care needs is carried out prior to admission. There was no evidence that any action had been taken to address this. Given that the manager has been in post a relatively short time it was agreed that she be given more time to address this shortfall. However it is important this is addressed quickly so that Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 9 detailed and significant information about residents care needs is recorded, in order to guide staff providing care. The manager is advised to refer the National Minimum Standards for Care Homes for Older People-Standard 3 to ensure all areas highlighted are covered in assessment documents. Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 7 Limited progress has been made to ensuring care plans have sufficient information to guide staff providing care and to make sure all care needs are identified and planned for. EVIDENCE: Individual plans of care are available but little progress has been made on the requirement made in the last inspection to ensure all aspects of health, personal and social care needs are identified and planned for. Four care plans were examined to they were very basic, not up to date and had not been reviewed. Significant information had not been recorded, daily entries in care notes had not been made and entries available gave little indication of the actual care given. This was evident in all of the care plans examined. For example in one plan it was noted that a resident had a “poor appetite” but she had not been weighed, a nutritional assessment had not been completed and there was no indication in care notes as to her food intake. Another plan indicated a resident’s behaviour was “challenging” but there had been no diary entries for eighteen days which would have given an indication whether there was an improvement or detonation. Additionally there Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 11 was no written information as to what action had been taken by the homes staff to address this issue. This was discussed with the manager who advised her GP had been contacted and a referral to a consultant had been made. None of this information was documented. It was also noted that service users health care records had not been filled in routinely. For example some had no entries while one residents health care record showed she was last visited by the chiropodist on the 18/11/04. In the case on one service user there was no care plan at all. It was also noted that care plans had not been signed and agreed by residents and/or their representatives. There was no evidence to suggest monthly reviews of care had been recently undertaken. All these areas need to be addressed as a priority. Discussion with staff suggested that some needs were being addressed even though there was a lack of clear plans and guidance. This approach is dependent on staff memory and good verbal communication. The reliance on verbal instruction and memory could easily break down resulting in residents not having their needs met. The manager indicated she had already identified care plans need to be improved upon, but as she had only recently taken up her post had not had the opportunity to address this issue. Given the situation an extension to the timescale for this to be rectified has been agreed. Improvements to the system of completing and reviewing risk assessments are needed. For example in some of the care plans there were no risk assessments at all. While in others risk assessments did not cover all relevant areas, any preventative measures or details of any reviews. These shortfalls must be addressed as a priority to ensure any risks to resident’s safety is identified and planned for. Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 12 & 14 The range of activities provided both inside and outside the home need to be improved upon in order to ensure residents social care needs are met. In the main personal support is offered in such a way as to enable residents to exercise choice and control over their lives. EVIDENCE: The home has a TV and music centre available for the use of service users. A range of age appropriate games is also provided. Currently activities take place on an ad hoc basis, there is no up to date information about activities available to residents. The activities residents take part in are recorded examination of which showed the last recorded activities took place on the 12/9/05 where residents took part in “soft ball games”. There was no evidence that residents are offered the opportunity to take part in activities outside the home. A visitor spoken to indicated there was “very little stimulation”. Some residents spoken to indicated more activities would be appreciated. A significant number of staff employed at the home are from overseas and the manager should be mindful there maybe some social differences and that care should be given to ensure that any preferences of the residents are met. Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 13 The range and frequency of the activities provided for residents needs to be improved upon in order for their social care needs to be met. A planned programme of activities needs to be developed which should be conspicuously displayed to inform residents of the choice of activities available. Also relatives may wish to know more about how residents spend their day or they may even wish to participate or assist with activities and outings. In the main residents expressed satisfaction with care provided and organisation of life at the home. Residents are able to personalise their rooms evidence of which was seen. The manager advised that residents were able rise and retire when they wished. Residents also confirmed this. A choice of menu is not available but staff advised an alternative would be provided if residents wished. During the last inspection residents were observed being offered alternatives. Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 18 Policies, procedures and training to protect service users from abuse are absent. These shortfalls need to be addressed to ensure service users are not at risk of abuse and harm and that staff are aware of how to respond to any allegation or suspicion of abuse. EVIDENCE: A procedure for responding to allegations of abuse was not available. Discussion with the manager took place in respect of the steps to take if a case of suspected abuse occurred. There was some confusion in regard to the action to take and whose role it is to investigate such incidents. This lack of understanding could potentially jeopardise any adult protection investigations. The manager was advised to obtain a copy of the local authority protection of vulnerable adults procedure and to familiarise herself with the procedure so that she knows how to respond to a report of suspected abuse. It was also noted in training records that staff had not routinely undertaken training in the protection of vulnerable adults to ensure staff are fully aware of abuse procedures and what action to take if such a situation arises. This needs to be addressed in the staff development programme and should be offered to all grades of staff. Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 19, 24 & 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. The outside of the building has been repainted. The hall, stairs and landing areas have also been redecorated. New curtains have been purchased for the lounge and dining area. During the last inspection the former manager advised that the lounge/dining areas were to be redecorated and re-carpeted. This has not yet been addressed. Bedrooms are personalised with photographs and personal mementoes on display. Doors are fitted with locks that can be opened by staff in an emergency. 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. However during the last inspection it was noted that while Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 16 functional wardrobes, lockers and drawers are old and show signs of wear and tear and a recommendation was made for these items to be replaced as part of a planned programme of renewal. This remains relevant and is once again recommended. It was noted that some double bedrooms have single occupancy. While this is acceptable the manager needs to be mindful this will reduce the number of residents that can be accommodated, as double rooms must be at least 16sq metres. The manager is advised that if rooms are to be shared service users must have made a positive choice to do so, and when shared rooms become vacant the remaining resident has the opportunity not to share. To demonstrate residents have been consulted about the possibility of sharing a room, detailed records of the consultation/discussion process need to be maintained. There was no evidence of this in resident’s records. This needs to be addressed in order to evidence residents have been consulted and have made the choice to share their bedroom. All areas of the home were clean and odour free. Residents 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 DS0000062654.V258301.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 30 Staffing levels are satisfactory but improvements to the duty rosters are needed to ensure sufficient information is provided in regard to the number and designation of staff working at all times. Staff have not received appropriate training which compromises the quality of care provided to people living in the home. EVIDENCE: On the day of inspection sufficient staff were on duty to meet residents care needs. The manager works on a supernumery basis Monday to Friday. Currently during the day there are two care staff, a cook and part time domestic. At the weekends and evenings two care staff are rotered to work. One member of staff covers the waking night shift, whilst one member of staff sleeps in. A written rota is maintained however it is not clear from the rota who provides on call cover at night and which member of staff is the designated senior. The manager needs to ensure the duty roster contains details of all persons working at the home with particulars of on-call cover and designated senior staff. The manager must forward 4 weeks rotas (including details on call cover and designated seniors) to the CSCI in order for the inspecting officer to assess whether staffing levels are sufficient. Discussion with the manager indicated that consideration was being given to reducing the number of hours the cook worked. As a consequence care staff would have to prepare the evening meal, which would take them away from the direct care and Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 18 supervision of service users. This is not advisable as it goes against recommended food hygiene guidelines in that staff must not undertake catering and care duties at the same time. If the cook’s hours were reduced an additional member of staff would need to be rotered to work to avoid care staff from engaging in catering and care tasks at the same time. It should also be noted that any staff preparing and handling food must complete food hygiene training. During the visit staff were observed to respond speedily to requests for assistance made by residents. Staff spoken to said current ratios were adequate. While residents said said staff were looking after them well, staff training is an area, which needs prioritising. There was no evidence to show any staff had undertaken induction or that ongoing opportunities are provided. The manager must ensure that staff undertakes induction training which meets NTO (national Training Organisation) specification within 6 weeks of appointment to their posts and foundation training within 6 months of appointment. Only two staff have attained NVQ (National Vocational Qualification) level 2. The manager is advised to undertake a detailed review so as to assess progress in meeting the required 50 target of NVQ qualified staff. To be followed up at the next inspection. From discussions with staff and training records seen it was evident staff had not received the training they require. For example the cook has not completed food hygiene training. Another area that needs to be addressed is in respect to mandatory training. The manager indicated not all staff had completed moving and handling training or first aid training. This needs to be addressed in the staff development programme. It was also unclear from staff records as to what training staff had completed. To evidence staff are receiving the training they need, a training record for each member of staff needs to be maintained, to include details and copies of certificates of courses undertaken, dates completed and dates refresher courses are due. Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 & 33 Quality assurance systems need to be improved to ensure the performance of the home is regularly monitored and to provide evidence resident’s views are sought and acted upon. EVIDENCE: Management at the home was not examined in detail as the new manager only recently commenced her duties. The manager is reminded she will need to make an application with the CSCI for registration. The manager is aware there are a number of issues she needs to address to meet the shortfalls identified during this inspection. To do this she needs some dedicated time where she can concentrate wholly on particular tasks for example improving and updating care plans, developing a staff training programme and introducing effective quality assurance systems. The manager does not have a formal management qualification but is aware she will need to undertake the NVQ level 4 registered managers award. Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 20 The home has a system for recording the complaints of those who don’t wish to complain formally. Residents are informed of CSCI inspections and inspection reports are available. All this is good practice but further development is needed to ensure quality assurance systems are effective. For example residents and a visitor confirmed the owner visited regularly and asked them for their views and opinions about the home, but no records were available in the home of these visits, which if documented would provide evidence the performance of the home is monitored and evaluated. It was evident in discussions with the manager that she needs to update her knowledge in regard to quality assurance. For example she was unaware if the home had a development plan or what areas the plan would cover. While it was apparent residents/representatives are consulted on an informal basis these discussions are not recorded. Resident meetings are not held and satisfaction surveys are not sent to residents or their relatives. All these areas need to be addressed to provide evidence the home is run in the best interests of the residents. Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 1 3 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 2 29 X 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X X Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement Assessments must cover all areas indicated in National Minimum Standard 3. Timescale 30/8/05 not met. 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. Timescale 30/8/05 not met. Risk assessments must be completed and regularly reviewed. Timescale 31/07/05 not met. A varied and regular programme of activities must be developed. A written policy must be drawn up for responding to suspicion or evidence of abuse or neglect. To ensure staff are fully conversant in abuse procedures staff must be provided with training. Documentary evidence must be provided that residents sharing bedrooms have made a positive DS0000062654.V258301.R01.S.doc Timescale for action 31/01/06 2 OP7 15 31/01/06 3 OP7 15 31/01/06 4 5 6 OP12 OP18 OP18 12 13 13 31/01/06 31/01/06 31/01/06 7 OP23 12 31/01/06 Windsor House Version 5.0 Page 23 8 OP27 17 9 OP28 18 10 11 OP30 OP30 18 18 12 13 14 OP30 OP31 OP33 18 9 24 14 OP33 26 choice to do so. To demonstrate staffing ratios are appropriate a recorded rota showing all staff that is on duty at any time and in what capacity must be maintained. Four weeks rosters to be forwarded to the CSCI in the timescale indicated. Action must be taken to ensure that 50 of staff attains NVQ level 2. Details of this to be addressed to be forwarded in the action plan. All new staff must complete induction training, which meets the TOPSS specification. A staff development programme must be developed to include all mandatory training including moving and handling and first aid. Details of how this is to be achieved to be forwarded to the CSCI in the timescale indicated. The cook must be registered to undertake food hygiene training in the timescale indicated. The manager must register to undertake the NVQ level 4 registered managers award. An effective quality assurance system must be developed with the results of surveys published and made available to service users, significant others and the CSCI. See body of report for details. The responsible person must visit the Home once a month and prepare and provide a written report as to the conduct of the Home in keeping with Regulation 26. 31/01/06 31/01/06 01/03/06 31/01/06 31/01/06 31/01/06 01/03/06 31/01/06 Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 24 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 Refer to Standard OP24 OP31 Good Practice Recommendations As part of the homes planned programme of refurbishment consideration should be given to purchasing new wardrobes, chest of drawers and lockers. The manager should be given dedicated time to address the shortfalls identified in this report. Windsor House DS0000062654.V258301.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office 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 DS0000062654.V258301.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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