Inspection on 05/02/07 for Windsor House

This inspection was carried out on 5th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Windsor House 22/06/09

Windsor House 02/12/08

Windsor House 19/12/07

Windsor House 09/05/06

Windsor House 01/10/05

Windsor House 12/04/05

Windsor House 23/11/04

Windsor House 30/07/04

Windsor House 19/05/04

Windsor House 19/11/03

Windsor House 07/10/03

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

CARE HOME ADULTS 18-65 Windsor House 9 Cabbell Road Cromer Norfolk NR27 9HU Lead Inspector Ann Catterick Unannounced Inspection 5th February 2007 01:45 Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windsor House Address 9 Cabbell Road Cromer Norfolk NR27 9HU 01263 511438 01263 511141 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Robert Jeans Mrs Sarah Jeans Position vacant Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Ten (10) people with a Learning Disability may be accommodated. Date of last inspection 9th May 2006 Brief Description of the Service: Windsor House is a care home providing personal care and accommodation for up to 10 adults with learning disabilities. The Registered Providers are Sarah and Robert Jeans. The present manager is Denise Appleton who is planning to make application to become the Registered Manager. The home is located very close to the sea in the coastal town of Cromer and is close to shops, pubs and all local amenities. Windsor House is a large Edwardian terraced property with accommodation on four floors. The property has been in a poor state of repair but the Proprietor is in the process of making some improvements in the home. Service users are accommodated on the first three floors. The weekly fee is between £320 and £360. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection and took place over a period of 5.5 hours on the 5th February 2007. Denise Appleton, manager is to make application to become the Registered Manager. Her application had not been received at the time of the inspection. There have been some improvements since the last inspection. Seven comment cards had been received from service users. All comments in the comment cards were positive. Most service users were assisted to complete the forms by care staff. Five comment cards were received from relatives. All of the comments from relatives were positive. The pre inspection questionnaire was not returned at the requested time and therefore was not in time to be studied prior to the site visit The quality of outcomes for service users are generally good and service users appear to be happy and content living in the home. There have been some improvements to the environment but there are still many aspects of the fabric of the home that need to be addressed and many of the furnishings are well worn. The manager has made some improvements to the home but still works regular shifts and this does not give her time to complete all of her managerial responsibilities and this was evidenced at the time of the inspection. The overall outcome for service users appears to be good and all service users either expressed positive views or if not able to communicate presented as relaxed and settled within the placement. Some examples of the comments made by service users: “I am the residents representative as staff say I can express my own and others opinions.” “We hope to go to Disney World later in the year.” “I am learning to read here.” “Staff listen to me and treat me well all of the time.” Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 6 Some examples of the comments made by relatives: “My relation has benefited in so many way since being at Windsor House.” “My relative has come on leaps and bounds all due to the wonderful staff.” Some examples of comments made by staff.” “If I was one of the residents I would like to live here.” “Independence is promoted and residents are treated as individuals.” “Staff work together as a team.” “There is a relaxed atmosphere here.” What the service does well: What has improved since the last inspection? The manager has sought information from the nutritionist about providing a varied well balanced diet that is both enjoyable and healthy for service users. The home now has clear guidelines for to protect vulnerable adults. The manager has devised a quality assurance system and is seeking views of service users, relatives and staff with regard the service provided. The radiator in the bathroom has now been covered. Care plans are much more user friendly and person centred. The manager has commenced her NVQ level 4 in management. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 7 Staff have been on several training days and training needs are being identified in the home. The medication keys are always kept on the person of the carer in charge of each shift and no longer kept insecure. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information about the home needs to give up to date information to service users to ensure service users and prospective service users have the correct information. Any assessment procedure used by the home needs to ensure that the needs of present service users are also considered as this is a small family run home. EVIDENCE: The Statement of Purpose and Service User Guide need to be updated to reflect the current staffing situation. Since the last inspection one service user has been admitted to the home as an emergency placement. On the day of admission the prospective service user visited the home with the social worker and health worker. Reports were received at this time and were seen on file. Prior to this the only assessment made by the home was by telephone. The service user was admitted to the home following this meeting. Assessment of need was made within the first couple of days of admission. The manager needs to ensure that when considering new admissions to the home the overall needs of all service users need to be considered. A recommendation has been made in this area. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 10 This relates particularly to the fact that the new service user is a smoker and the home has no separate area for this activity. The new service user has settled well into the home and was happy to tell me about their room and to let me look at their care plan. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There has been significant improvement in the content and presentation of care plans and this enables service users to own their care plans and be more involved in them. There is still some work to do however when done the outcome for this area should be good. EVIDENCE: Four care plans were inspected. The manager has started to devise care plans that are much more service user centred and significant improvement has been made in this area. The format used was easy to understand and had been completed with the service users. Service users whose care plans were inspected gave permission for to happen and one talked the inspector through the plan. There is still some further work to do with the care plans and the manager is to devise a plain English risk assessment record. A recommendation has been made in this area. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 12 All service users have a key worker and this system appears to be working well. The care plans are to be reviewed at least every six months. Dreams and aspirations have been identified within the care plans and staff should support service users to realise these, wherever possible. All staff spoken to were very clear that it is important for service users to have choices and staff aim to encourage independence in all areas. One service user had a support worker from the Independent Living Organisation to support and encourage independence and interaction outside of the home. User-friendly comment cards were given to service users and those who needed it were assisted to complete the form. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The lifestyle of service users appears to meet their needs and expectations. There is still opportunity for further development however this outcome area is met. EVIDENCE: Service users have different levels of activity and occupation during the day depending on need and preference. Some attend the adult training centre and others attend break or a mixture of the two. Three service users do not attend any specific day centres during the day. On the day of inspection 5 service users were at home. The manager was aware that the local ATC was not meeting the needs on one service user and this was being looked into with the view of finding a more suitable occupation or learning placement during the day. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 14 Service users have access to the local community facilities with some visiting the local pubs or café’s. The home is very near the sea front and shops and this enables service users to have easy access to all local facilities. Two staff should be on duty at any time when service users are at home and staff said that this gives the opportunity for them to take service users out. The home does not have its own transport and the manager uses her own car if need be. A homes vehicle would give more choice to service users. A recommendation has been made in this area. There are plans for a trip to Disneyland later in the year. Daily routines are tailored to the individual needs and preferences of service users. This was noted at teatime when service users were having tea at different times as this was their preference. The manager has sought advice from a nutritionist as there had been concern about the quality and variety of food provided in the home. The nutritionist identified several areas to encourage a more healthy diet for service users and the manager needs to ensure that the advice is reflected in the menus. Service users do have choice at meal times. The choices could be made more varied given opportunity for service users to try different types of food. Menus were improved and the tea on the day of inspection was well presented. There has been improvement in this area. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health needs of service users appeared to be met and good links were had with professionals. There are still some areas where improvement is needed with regard medication practice. EVIDENCE: The service users living at Windsor House need no nursing care and limited personal care. Those care plans inspected identified what personal care needs there were and, where able, service users had involved in the creation of their care plans. For example what help they would like with bathing or when they may needs assistance with other personal care needs. Within the comment cards received all service users said that they were well care for. The home users the key worker system and those service users spoken to were aware of who their key workers where. The home has a good relationship with local health and social workers. Within care plans specific healthcare needs are identified and links made with appropriate health care workers. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 16 A service user who had been admitted to the home on a temporary basis and self-administered medication whilst at home was not looking after their own medication in the home. The manager had explained that this decision had been made following a risk assessment but none of this was recorded and therefore it appeared the right to self medicate had been taken away even though this may not have been the case. A requirement has been made in this area. Medication records were generally OK but it was noted that one medication that had been administered at lunchtime had not been signed for. This is not safe practice. A requirement has been made in this area. Medication keys were seen to be with the senior person on duty and were not left unsecured. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There have been significant improvements in this area that ensure that service users are listened to and that they are protected from abuse. EVIDENCE: The new care plans give clear information in plain English to inform service users and their families how to make a complaint and includes contact details of the CSCI. This easy to read format needs to be included in the new Service User Guide. Those service users who were able to give a view felt they would be comfortable making a complaint and in comment cards several service users identified who they would speak to. Staff have now received training regarding adult protection and evidence of this was seen on staff files. A copy of the Norfolk Adult Protection Policy is now available for staff in the downstairs office. The home has and old-fashioned policy that could be discarded and a new policy for staff that relates specifically to the Windsor House could be devised to ensure staff on duty were aware what to do in any given situation. A recommendation has been made in this area. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment is not homely and comfortable in all areas and the smell of smoke throughout the whole of the ground floor does not give a safe environment for non-smoking service users to live. Generally the environment remains poor. EVIDENCE: It is disappointing to see limited improvement in the environment since the last inspection. On arrival into the home the lobby area smelt of smoke and this was drifting up the stairs towards the bathroom and service users bedrooms. The inspector was also made aware that smoking had been taking place in the lounge and dining areas. If the home accommodates service users that smoke Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 19 the proprietor needs to ensure that there are smoke free communal areas for those who do not smoke and that the smoke fumes do not reach the bedroom areas. A requirement has been made in this area. The carpet in the lounge had been replaced with carpet tiles and a stack of these were in the hall at the bottom of the stairs causing a hazard. The cushions in the lounge had no covers and when questioned staff said that one service user takes them off so they are no longer put on. This is not good practice and an alternative needs to be found. A new television has been purchased for the lounge. Most furniture is well worn and could be replaced. The dining area and kitchen area were bright and welcoming places to be. Locks have now been put on the bathroom and toilet doors and radiators have been covered or risk assessed as being of no or limited risk. The hot water in the bathroom tap was too hot and the proprietor needs to ensure that water temperature requirements are met. A requirement has been made in this area. Window restrictors are now on upstairs windows where service users have access. The home was warm on the day of inspection however the inspector was informed that there had been no heating at the weekend as the boiler had broken. This has now been repaired but this was not the first time this had happened. Bedrooms are adequate, with some decoration and refurbishment taken place and some more to be completed. There was no lampshade in the bathroom. The toilet on the first floor is still not usable and has been awaiting refurbishment for over a year. The laundry room is in the cellar and has never been refurbished. It must be difficult to control infection with the walls and floor being unfinished. . It has a small sink. This area is also used for storage being cluttered with various items. One service user uses the laundry but due to being in the cellar is not a facility that all service users could access if they chose to do so. As a laundry room this is not adequate. A requirement has been made in this area. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff have received training and appear to work well within the home. Due to poor administration and practice the home does not have a foolproof safe practice regard recruitment and selection. EVIDENCE: There has been one new member of staff appointed since the last inspection. Her records were inspected and it was noted that only one reference had been received. The manager said she had spoken to another referee by telephone but this was not recorded in any way. A requirement has been made in this area. A copy of the GSCC book was on file and it is assumed the worker has read this. It may make more sense to give employees a copy of the book for easy reference. A recommendation has been made in this area. Within the staff file several policy documents, a job description and application form were seen. There was no way of knowing when the staff member commenced work as this was not recorded in the staff file and the manager had to look back at rotas to find the date. It was noted that the employee commenced work prior to any references being received. A requirement has Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 21 been made in this area. Evidence of CRB was seen on file but dates of POVA first checks were not clear. A requirement has been made in this area. Due to staff sickness the manager has covered many shifts. This is not appropriate and the home needs to ensure that enough staff are employed to meet the needs of service users. This may mean the use of agency staff or employing relief staff when there are not staff available to cover shifts. Staff have received significantly more training since the last inspection. This includes medication training, first aid training, food hygiene and POVA training. Training with regard health and safety and dealing with challenging behaviour is planned for the near future. Informal supervision of staff takes place but formal supervision is limited. On the day of inspection one staff member’s mobile phone rang at least twice whilst the staff member was working with service users and this was seen as inappropriate. The manager has been advised to consider a policy with regard staff mobile phones as this continual distraction could have an impact on the care provided. A recommendation has been made in this area. The manager needs to ensure the safety of staff and as staff have to go up and down stairs flip flop slippers, seen on the day of inspection, may not be appropriate footwear. A recommendation needs to be made in this area. Staff spoken to on the day of inspection spoke of how they believed choice and empowerment was promoted for service users within the home. They said they worked in a way that was person centred and tried to follow what service users wanted and needed. Good practice was observed in this area. Staff described the home as being very relaxed, home from home, and felt the staff team worked well together and were supported by the manager. Staff felt positive about recent training that had been offered. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff have received training and appear to work well within the home. Due to poor administration the home does not have a foolproof safe practice regard recruitment and selection. Evidence suggests staff could be better managed. EVIDENCE: The manager is to make application to become the Registered Manager but had not sent the forms of at the time of the inspection. The manager has begun her Registered Manager Award and hopes to complete it later this year. The manager has started to devise a quality assurance system to measure the quality of all aspects of care provided. This was seen as good practice. . It was disappointing to see that the manager had worked 10 carer shifts and only 3 office shifts with one day off within the past two weeks. The manager needs to be able to spend her time managing the home and will not be able to do this if she is in a carer role for much of the time. A recommendation has Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 23 been made in this area. The Pre Inspection Questionnaire was due to be returned to the Commission on 15/02/07 and was not returned by the day of inspection. It was in transit so could not be looked at within the site visit. This is an example of management tasks not being completed. It was nearly three weeks overdue. Formal supervision is not taking place and no supervision is recorded. A requirement has been made in this area. The manager would see her management role as liaise-faire but needs to ensure that there is some management structure within the home. The manager has a good relationship with staff and service users and has an open and transparent way of working. Since being in post she has begun to develop good practice and this can be evidenced in the improved care plans, staff training and the work completed on quality assurance. The manager has begun to review policy and procedures and these should soon all be up to date and/or amended. Since the last inspection all staff have completed training relating to the health and safety of service users, including first aid and food hygiene. Service users’ finances are managed by the Proprietor of the home. An error was identified in one record showing that a service user had paid for the same item twice. This appeared to be a genuine error on behalf of the Proprietor. This highlights the need for regular audit of looked after money to ensure records are correct. There was an issue regarding security and fire exits at the last inspection and the manager has been trying to engage the fire service in this area. As an interim measure and after speaking to a the person who services the fire appliances the manager has put a lock on the fire exit on the first floor as it is thought only to be a fire escape for Windsor house not the adjoining properties. This needs to be monitored and well-documented and further discussion with the fire officer needs to be had. All staff are receiving induction and foundation training but induction books could not be seen as the staff kept these at home. The inspector does not have the knowledge to fully inspect standard 42.4 but assumes that the Proprietor is compliant with the legislation listed. Some risk assessments were seen and where appropriate the manager is to rewrite these in a way that individual service users will understand. A business and/or financial plan were not seen on the day of inspection. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 x 26 x 27 x 28 2 29 x 30 1 STAFFING Standard No Score 31 x 32 2 33 x 34 1 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 3 3 2 x x 2 Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13.2 Requirement The registered person must ensure that service users who are able to administer their own medication are enabled to do so unless recorded risk assessment identifies why this should not happen. This relates particularly to a service user who is in the home on a temporary basis and self medicates when at home. The registered person must ensure that all medication administered is signed for at the time of administration in the medication administration record. The registered person must ensure that all water outlets to which service users have access are of the recommended safe temperature. The registered person must ensure that the laundry area is in a state of good repair and ensures the control of infection. This area should also be easily accessible to service users. The registered person must ensure that all of the required documentation regarding DS0000027290.V329873.R01.S.doc Timescale for action 01/03/07 2. YA20 13.2 06/02/07 3 YA24 14.4 01/03/07 4 YA30 16.f 23.2 01/07/07 5 YA34 19 01/03/07 Windsor House Version 5.2 Page 26 prospective employees is received by the home prior to staff commencing work. This relates particularly to POVA first checks and references. 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 5 6 7 Refer to Standard YA2 YA7 YA23 YA14 YA31 YA36 YA36 Good Practice Recommendations It would be good practice to take into consideration the needs of all service users living in the home when considering a new admission. It would be good practice to have Risk Assessments in care plans that can be understood by service users. It would be good practice to have clear guidelines for staff re adult protection that relate specifically to Windsor House. It would be good practice to own or have regular access to a mini bus to enable service users to access social activities further a field. Copies of the General Social Care Council booklets were seen in staff files and it may be more appropriate that staff have these to read and refer to. It is recommended that the home have a policy with regard the use of staff mobile phones whilst on duty. It is recommended that the dress code for work include advice with regard footwear. Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Windsor House DS0000027290.V329873.R01.S.doc Version 5.2 Page 28 - 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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