Inspection on 09/05/06 for Windsor House

This inspection was carried out on 9th May 2006.

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 no outstanding requirements from the previous inspection report, but made 8 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 05/02/07

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 9th May 2006 01:00 Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 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.V294562.R01.S.doc Version 5.1 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.V294562.R01.S.doc Version 5.1 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 Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Ten (10) people with a Learning Disability may be accommodated. Date of last inspection 1st October 2005 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 manager, made application to become the registered manager but her application was refused. The previous manager is now a senior carer and the home, at present, has no 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. Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was a key inspection and the fieldwork visit took place on the 9th of May 2006 over a period of 7hours. Since the last announced inspection, Rachael Stevens, the manager for the home made application to become the registered manager but her application was not accepted. She is now a senior staff member within the home. The Proprietors have been advised of the importance of appointing a new manager with the view to them becoming the registered manager but no manager has yet to be appointed. The lack of management in the home has an impact on the service provided as there appears to be no one person taking responsibility for the overall quality of the care. The practical care of service users is generally good but other areas such as environment, policies and procedures and recording of progress are lacking. These areas can have an impact on the care provided and the safety of service users. One area that caused particular concerns was the practice around the recording of the administration of medication. Although staff had received training in this area poor practice was evidenced at the time of the inspection and this poor practice put service users at risk. An immediate requirement was made in this area. A competent manager would have identified the areas of concern as they reviewed the quality of the service. Without a competent manager it is unlikely that there will be any significant improvement within the home. Prior to the fieldwork visit 7 comment cards had been received from relatives and all made positive comments about the home and the care their relatives received. Examples being: “Very clean, good food and happiness. “Nothing is too much trouble.” “ My relative is very happy.” A professional who has access to the home spoke positively about the care provided although felt there were not always enough staff on duty. All comments from service users were positive saying that they liked living in the home and felt well looked after. Senior staff completed a feedback questionnaire although this had not been completed as fully as it might have been. Some improvements have been made to the environment but further improvements are needed to bring the home up to good standard. The quality of outcomes for service users are generally good and service users are appear happy and content living in the home. Staff are committed to providing good care and encourage independence and choice. The areas of concern relate to the overall lack of management in the home and the lack of quality assurance systems and self -audit. Without safe systems Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 6 and procedures underpinning the care provided there is always the potential of incident or accident occurring. What the service does well: What has improved since the last inspection? What they could do better: The Proprietor must ensure that the home has a competent manager as the home has been without a manager for some time. There is no manager in the home and there is no evidence that the home has a system for measuring the quality of the service. There is no monitoring of the service provided. The Proprietor needs to ensure that all senior staff are aware of the procedures relating to adult protection as the senior member of staff on the day of inspection was not clear in this area. Staff were not following safe procedures for the recording of the administration of medication. This was very concerning as medication had not been signed as given in the medication record for two days. The poor practice was from staff who had received medication training and would have been advised of the Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 7 correct procedure. This poor and dangerous practice not been picked up by the senior staff on duty over that period. Menus seen were basic lacking imagination and there was no evidence of the nutritional value of meals being considered. Most service users have a packed lunch during the day and would need a substantial meal at tea- time. Although some improvement has been made to the environment further improvements need to be made. Several carpets are well worn and stained, needing replacing. Some radiators are still not covered and could pose a risk to service users. 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 DS0000027290.V294562.R01.S.doc Version 5.1 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.V294562.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 The overall quality outcome of these standards is poor. The home has a Statement of Purpose and Service User Guide that are adequate, but could be more user friendly. One care plan inspected had no documentation relating to any assessment, completed by the home or the professional placing the person. EVIDENCE: The home has a Statement of Purpose and Service User Guide and these give relevant information. However they are not written in plain English and no thought has been given to the particular communication needs of the service users. A recommendation has been made in this area. The file/care plan of a service user who initially was admitted as an emergency was inspected. There was no documentation to evidence that an assessment had been completed by the home prior to admission. It was unclear as to how the home had assessed that the person’s needs could be met as there was no assessment from the placing professional. As the admission had been an emergency these documents and any relevant information should have been collated in no more than five days after admission. A requirement has been made in this area. Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 The overall quality outcome for these standards is adequate. No personal goals were reflected within individual care plans and service user and/or their families appeared to have little involvement with care plans. Service users appeared to be able to make appropriate decisions about their lives although details of this were not always recorded in the service user care plan. Service users are supported to take risks but the documentation needed is not always complete and in place. EVIDENCE: Care plans were seen and these had some relevant information regarding the service user. The format used was rather muddled and included some information that should have been stored in the service user file. There was some good and relevant information but it was difficult to track progression. For example one care plan gave information relating to supporting a service user to become more independent and to eventually return to living in the community. However there was no recording of what staff were doing to Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 11 follow this part of the care plan. The care plan had been reviewed and no change to the plan was made. When this was discussed with a senior member of staff she was able to say what was happening but acknowledged that this has not been recorded. It would therefore be difficult for staff to offer continuity in this area. Some risk assessments were seen in care plans but there was opportunity for these to be more clearly linked with the care plan as a whole. No nutritional records were seen on file and weight charts had not been completed for several months. The home does not have a system of self -audit or quality assurance. This is clearly demonstrated in this area as no one is measuring the quality of care plans or relating their content to the requirements within the Care Home Regulations 2001. A requirement has been made in this area. Staff encourage service users to make decisions about their own lives. Staff spoken to felt that individual needs and preferences were important and that service users should be encouraged to be as independent as they were able to be No service user was able to manage their own finances and the home supported service users in this area. Some risk assessments were seen in care plans. Some of these were adequate and others could be more detailed. Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 The overall quality outcome for these standards is adequate. Service users are encouraged to take part in educational and occupational activities that they enjoy doing. Service users have links with the local community depending on their preference. Families and friends are welcomed in the home with the agreement of service users. Staff promote service users rights and aim to promote independence and encourage choice and independent thinking. Service users were seen to enjoy their meal on the day of inspection but nutritional value of meals provided was not measured and there was concern that meals identified on the menu sheets offered limited nutritional value. Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 13 EVIDENCE: The way service users spend their days depends on their preference and abilities. For example on service user attended the adult training centre 5 days a week and also enjoyed swimming a singing lessons. Another service user had reached retirement age and had recently stopped attending the day centre. The senior staff were planning to look for other activities and occupation for her to become involved in if she chose to do so. Another service users attended the adult training centre four days a week and had one day off during the week. She also spent time at college to develop her literacy skills and art and craft skills. There was limited information, in care plans, with regard to education and occupation and how this linked with goals and aspirations. Generally this outcome was met but more detailed recording about what service users are involved in should be done. A recommendation has been made in this area. Windsor House is in the centre of the seaside town of Cromer and those service users who can go out independently or go out with staff use the facilities within the town on a regular basis. The home does not have a mini bus but would hire a mini bus when service went out as a group or needed to travel outside of the local area. On the day of inspection one of the service users was attending an activity in the local church. No relatives were seen on the day of the fieldwork visit however seven comment cards were received from relatives and all comments were positive saying that staff were caring and competent and that the quality of the service was good. The staff spoken to on the day of inspection said that they encouraged independence and choice. Staff felt that some of the service users had previous experiences of living in fairly rigid environments and that they were now encouraged to have more control over their lives. Some evidence of this was seen on the day of the fieldwork visit. For example at tea time some service users chose to eat in the dining area, some chose to eat in the lounge and others chose to eat outside the home on the patio. Comment cards were received from all service users and they suggested that service users are happy and satisfied with their care feeling they have choices in their lives. Prior to the fieldwork visit the home provided menu charts. Several of the service users have a packed lunch during the day and their main meal at teatime. The tea -time menus were limited considering they were the main meal of the day for some service users. Considering the variety of meals that could be offered many choices were repeated over a three week period. There was no documentation relating to nutrition in the kitchen or within care plans. There appears to be no quality assurance systems relating to food, meal times and nutrition. A requirement has been made in this area. Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The overall quality outcome for these standards is poor. Service users were seen to be offered support in a way that they preferred and required. Service users were seen to be having their physical and personal needs met. The staff were not following good practice with regard medication procedures and this could put service users at risk. An immediate requirement notice was issued in respect of medication concerns. EVIDENCE: The home is small and has a small staff group who are able to develop a good understanding and knowledge of the needs and preferences of all of the service users. The home has a key worker system. On the day of the fieldwork visitor staff were seen to interact well with service users meeting need and respecting choices and preferences of service users. The fieldwork visit commenced at 1pm on the 9th of May and there was no record of the administration of medication since the evening of the 6th of May. All staff administrating administration had received the Boots medication training and would be aware this was poor practice. Those staff administering Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 15 medication included senior staff. Some of the recording had been completed in pencil. Staff were observed transferring medication from the original container to a small dossette box and this secondary transfer of medication increases the risk of error. The medication policy was of little use and outdated. Generally there was poor and unsafe practice in this area. The concerns were so significant that an immediate requirement was made in this area. Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. The overall quality outcome of these standards is poor. The home has a complaints procedure although this needs to be revised and updated. Those service users spoken to felt that any concerns they may have would be listened to. The senior member of staff on duty at the time of the fieldwork visit did not have access to, or knowledge of the policies and procedures that were in place to protect service users. EVIDENCE: The home has a complaints procedure but this has some outdated information and would benefit from being updated. See recommendations. There have been no complaints since the last inspection. Those service users spoken to said that they felt comfortable speaking to staff about any concerns that they would have. All service users able to express an opinion had never made a complaint. Feedback form relatives suggested that they had never felt the need to complaint about any part of the service. The senior member of staff on duty could not find any of the procedures relating to local adult protection processes and the home’s policy was outdated and contained incorrect information. This was of concern as if an adult protection incident had taken place the senior member of staff on duty would be unclear on what procedures to follow. A requirement has been made in this area. Staff spoken to were confident about what to do if they saw any behaviour towards service users that caused them concern and would share their concerns with the manager. Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The overall quality outcome for these standards is adequate. There have been some improvements to the environment to make it more comfortable, however further work needs doing to improve the general standard. Most areas of the home were clean and generally tidy although some carpets needed replacing and decoration was needed in some areas. EVIDENCE: There was no evidence of a detailed maintenance plan and no suggestion that an audit of the quality of the environment on a regular basis. On the day of the fieldwork visit it was noted that a fire door that should be closed at all times or held open by the fire closure mechanism was not working correctly and was held open with a wedge which made the fire door unsafe. When identified by the inspector as unsafe a member of staff was able to refit the fire closure mechanism and make it work correctly. If an audit of the environment was carried out on a regular basis this would have been rectified much sooner. The inspector was informed that a programme of monthly maintenance meetings had recently been arranged and these should identify any issues relating to the environment. The home has a carer with a particular interest Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 18 and skills in general maintenance and he had been completing some of the decoration. There is a damp area on an outside wall in one of the bedrooms and this has meant that the whole room will need redecorating. The damp has been caused by an external problem and this is to be rectified soon and then the room will be repaired and redecorated. The lounge and dining area have been decorated since the last inspection and these offered brighter and more pleasant communal areas. Thought had been given to fixtures and fittings and a large mirror had been placed in the dining area. The bathroom is now completed and this clean bright and homely. Some of the bedroom carpets are stained and carpets in general are well worn and several need replacing. A recommendation has been made in this area. Not all radiators were covered and these included a radiator in a bedroom, communal area and shower room on the second floor. A requirement has been made in this area. The laundry area is in the cellar and has not proper floor or wall covering. On the day of the fieldwork visit a service user came down to the laundry room. This area needs to be included in any programme of maintenance and renewal. A recommendation has been made in this area. Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. The overall quality outcome for these standards is adequate. The roles of staff are clear to service users and staff are clear about their responsibilities. Staff are offered training to improve practice and increase knowledge but evidence suggested that staff do not act in a competent way in all areas. The home has a recruitment and selection policy but this had not been followed fully on all occasions. Some evidence was seen relating to induction training and all staff are encouraged to complete NVQ training. EVIDENCE: Staff were seen to interact with service users in a caring and competent way. Staff are encouraged to complete NVQ and at the time of the fieldwork visit 3 of the 7 staff had their NVQ level 2. Other staff are in the process of completing their NVQ level 2. Staff have had training in regard to medication and food hygiene. One member of staff is completing a communication course and aims to share the skills and knowledge learnt with other staff. A concern identified was that staff have had training with regard medication but those staff who have had the training were practicing in an unsafe way. The Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 20 responsible person needs to ensure that theory learnt in training transfers to practice. The home has a recruitment and selection policy and evidence of this was seen on the day of the fieldwork visit. References were seen and some documentation relating to the interview process. Evidence was seen of a CRB for some staff but for one member of staff an old CRB was on file and a new CRB had been applied for but no evidence of the POVA first check was on file. A requirement was made in this area. Evidence was seen relating to induction and foundation training and this was confirmed when talking to staff. Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The overall quality outcome for these standards is poor. The home has not had a registered manager for some time and at present does not have a manager. This has had an impact on the quality of the service provided. The home has no quality assurance systems in place and this has a clear impact on the service provided. The promotion of the health, safety and welfare of service users is the aim of staff, however, this is not always achieved. EVIDENCE: The manager of the home made application to become the registered manager but was not successful. This person is now a senior carer within the home. Since that time there has been no manager and the proprietor has been encouraged to appoint a competent person as manager as soon as possible. There was no manager in post at the time of the fieldwork visit. It was evident Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 22 at this visit that the home is not being managed. A requirement has been made in this area. The physical and emotional care needs of service users were being met and there were not significant concerns in these areas. The home has no quality assurance system in place and this has an impact of the quality of service provided. Several of the concerns identified at the time of the fieldwork visit would have been identified by staff and management at the home if there was a system to audit all areas of the service. For example the fire door release mechanism would have been identified as a risk and dealt with. The poor practice relating to medication would have been picked up and dealt with. Some of the worn and soiled carpets would have been identified as of poor quality and hopefully replaced. The lack of information regarding goals and aspiration in care plans would have been identified and acted upon. Until the home has ways of measure improving, monitoring and reviewing its service it is unlikely that improvement will be made and maintained. With no manager within the home the proprietor needs to ensure the outcomes for this standard are met. A requirement has been made in this area. No evidence of manual handling training was seen on file. Most service users are independent in this area and have no need for support with regard moving and handling but staff need training in this area to ensure any service users that are assisted are assisted safely. Fire training has taken place. On the day of the fieldwork visit the dining area fire door was made to work correctly. It was disappointing that some staff were aware of this issue but had done nothing about it. Staff have had food hygiene training. Two staff have a current first aid certificate. The maintenance records for the home were not looked at in any detail and will be inspected at the next inspection. The pre inspection questionnaire advised that the maintenance of systems and appliances in the home were up to date. Radiators were not all covered and a requirement has been made in this area. The Inspector did not feel competent inspecting against standard 42.4 but was informed that the home complies with the relevant legislation identified within this part of the standard. Any accidents or injuries are recorded and reported. Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 1 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 2 23 1 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 x 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 1 x 1 1 x x 2 Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 24 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 YA2 Regulation 14(1) Requirement The registered person must ensure that prior to admission, or within five days in the case of an emergency, an assessment is completed identifying need. The registered person must ensure that service users are provided with suitable, wholesome and nutritious food. This is a repeat requirement that was first made on 01/11/05. The registered person must ensure that all staff who administer medication are able to do this in a competent way. An immediate requirement was made at the time of inspection. The registered person must ensure that the home has a policy and procedure for the protection of the service users and that staff are aware of and have access to this policy. The registered person must ensure that all radiators are covered or that risk assessments have identified that they are of no risk to service users. This DS0000027290.V294562.R01.S.doc Timescale for action 01/06/06 2. YA17 16(i) 01/07/06 3 YA20 13(2) 01/07/06 4 YA23 13(6) 01/06/06 5 YA24 13(4) 01/07/06 Windsor House Version 5.1 Page 25 6 YA34 19 7 8 YA37 YA39 8 24 relates particularly to the radiators in the shower room and bedrooms. The registered person must 01/06/06 ensure that all of the documentation needed as described in Schedule 2 of the Care Home Regulations 2001 is collated prior to staff commencing employment. The registered person must 01/08/06 ensure that a manager is appointed to the home. The registered person must 01/08/06 ensure that a system for reviewing and improving the quality of service is in place. 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 Refer to Standard YA1 YA9 YA12 YA22 YA24 YA24 Good Practice Recommendations It would be good practice to revise the Service User Guide to make it more ‘user friendly’ and to consider any special needs that service users may have. It would be good practice to revise the risk assessment forms to ensure that they give detail of how risk will be minimised. It would be good practice to include more details in the care plans relating to the goals and aspirations of service users. It would be good practice to revise the homes Complaint’s Procedure to ensure this has all the up to date information. It would be good practice to review the condition of carpets within the home and replace any well worn or stained carpets. It would be good practice to refurbish the laundry room to ensure that this environment meets need. Windsor House DS0000027290.V294562.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 DS0000027290.V294562.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!