CARE HOME ADULTS 18-65
Windsor Lodge 43 Cranford Avenue Exmouth Devon EX8 2QD Lead Inspector
Belinda Heginworth Key Unannounced Inspection 13th July 2006 09:15 Windsor Lodge DS0000063309.V290495.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 Lodge DS0000063309.V290495.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 Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Windsor Lodge Address 43 Cranford Avenue Exmouth Devon EX8 2QD 01395 263211 01395 223154 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) Networking Care Partnerships (SW) Ltd Karen Farrelly Care Home 11 Category(ies) of Learning disability (11), Physical disability (11), registration, with number Sensory impairment (1) of places Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26th January 2006 Brief Description of the Service: Windsor Lodge is a detached three storey building in a residential area of Exmouth. The home also has a one-bedroom annexe. The main house provides accommodation and personal care for up to 10 service users with a learning or physical disability over the age of 40. The annexe provides personal and supportive care for one service user. Although both the annexe and main house are registered as one home. They tend to run as two separate units. Southern Cross Health Care has taken over the operations of the home with a subsidiary company called Active Care who is in charge of general operations. The home’s current fees range from £427 to £2987 with extra costs for personal items such as hairdressing, toiletries and so on being charged individually. Inspection reports are displayed in the entrance hall of the home, making them available to visitors and service users who wish to read them. Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5.25 hours with the manager being present throughout. Prior to the inspection surveys were sent to 10 service users, 10 staff and five relatives. Comment cards were also sent to two GPs and two care managers. Ten surveys were received from service users with the help and support of staff, four staff surveys were returned, two comment cards from GPs and one from a care manager were also received. No survey response was received from relatives however telephone contact was made with one. The manager of the home completes a questionnaire prior to the inspection. This provides the Commission with information and evidence about service users, staff and necessary policies and procedures. Four service users were consulted and their views on the home and their care discussed. The remaining service users have limited verbal communication skills and were therefore unable to contribute fully to the inspection process. However, time was spent with all service users and observations were made throughout the inspection. The inspector looked at number of records, including “case tracking” two service users’ files during the course of the inspection and a tour of the property took place. Three members of care staff were consulted and observed. Time was spent with the manager and the operational manager. Feedback was provided to both at the end of the inspection. What the service does well:
The atmosphere at Windsor Lodge is homely, friendly, caring and fun. Staff were observed being kind, respectful and offering choices to service users. The relationship between staff and service users was clearly trusting and caring. Staff are provided with good information about service users before they are admitted and while staying in the home. This ensures staff are aware of service users’ needs and have guidance on how to meet their needs safely. Much of the information is service user focussed taking into account their wishes and goals. The staff team work hard to ensure service users’ social needs are well met. Many attend groups outside the home for learning life and independent skills. Spiritual needs are catered for with weekly church attendance and visits from the local church. Service users talked about trips to gardens, picnics, and
Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 6 evening clubs, shopping trips, swimming and many more. Staff were very motivated in enabling service users to have these opportunities. The food provided in the home is healthy and varied with service users being offered choices, supported in preparing and making there own breakfast and lunches. Although menus weren’t used by displaying a set meal for the day a variety of options were displayed. Staff and service users said they were informed of choices of main meals and alternatives were always provided. Service users’ health and personal needs are supported and well met, some service users confirmed this and observations and records provided further evidence. Service users are listened to and fully protected from potential abuse or harm through good recruitment practices, good staff training, and clear complaint’s and financial procedures. The staff team are well trained, skilled and experienced and are very motivated to provide a good service. The current staff numbers meets the needs of the current service user group, with one service user receiving one to one care and in some instances two to one. Feedback from service users, a relative, staff, GPs and a care manager, before and during the inspection indicated that the manager runs a good service. Staff said she was very supportive, worked hard and provided a clear sense of direction. Service users who were able spoke highly of the manager. Throughout the inspection the manager was observed being kind, caring, working hard and giving clear instructions to staff. The new organisation has developed a quality assurance system that requires the manager to carry out a monthly audit on how the service is being run. In addition to the monthly audit the manager is required to seek the views of service users, relatives and staff to ensure the home is being run in the best interests of service users. What has improved since the last inspection?
Service users now have terms and conditions of living at the home that provides information about what costs might occur in addition to the home’s weekly fees. Care planning has improved which results in staff having clear information to meet service users’ needs safely. Service users have individual goals set which staff support and help them to work towards achieving. The information about the goals is more accessible to staff, which means they are being followed and recorded in a more meaningful and useful way. Staffs’ competences in relation to medication practices are beginning to be assessed ensuring service users’ welfare is better protected.
Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 7 Quality audits by the manager have significantly improved and audits by the provider now include checking service users’ finances. Service users are therefore better protected from potential abuse and are ensured the home is run in their best interests. During the last inspection in January 2006 it was highlighted that many areas outside of the home were potentially unsafe and look un-kept. For example, the fencing surrounding the house was broken, the path leading to the front door was poorly lit and very uneven and at the side of the house, the path and driveway was uneven. The poorly lit paths and uneven surfaces made it unsafe for service users to use independently. A requirement was made for this work to be completed by March 2006. The back of the house’s fence and surfaces has been completed and the work for the front of the house’s fence and path is due to start soon. The time scale for completion has been extended to October 2006. Clear assessments have been completed relating to uncovered radiators ensuring there is clear action to reduce risks to service users while waiting for them to be covered. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Windsor Lodge DS0000063309.V290495.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 Lodge DS0000063309.V290495.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with good information about the home and the costs. The manager gathers enough information to ensure the home is able to meet service users’ needs prior to admission. EVIDENCE: The home has a Statement of Purpose that provides relatives and professionals with information about the home. An easier to read guide for service users has been produced to help service users understand the services they should be provided with. Information about fees, services and what service users are expected to pay extra for is included in the home’s terms and conditions. These are provided to each service user. A fairly recently admitted service user’s file was read and was found to have good information gathered prior to admission to ensure the home could establish whether it could meet their needs safely. Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided with good information to meet service users’ needs and goals safely. Decision-making processes are excellent. EVIDENCE: The manager completes plans of care for each service user. The care plans set out individual needs, goals and any associated risks. This enables staff to have the information they require to help meet service users’ needs safely. The manager and staff are in the process of updating these to ensure they meet with the requirements and standards of the new organisation. A service user confirmed their involvement in the drawing up of their care plan. A relative and a care manager also confirmed that they attended regular care plan reviews. Staff demonstrated an excellent knowledge of service users’ needs, mainly through their years of working in the home, but said they were starting to use care plans more and followed the service users’ individual goals. This was also observed throughout the inspection. Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 11 Discussions took place with the manager about the best way to make information more useable for staff. Currently the information, which is very detailed, is kept in one folder with dividers, this makes the folders very heavy to carry and less easy to read. The manager is considering having separate, smaller folders for each heading to make them easier to access and read. Through discussions between service users and staff individual goals have been set for each service user. The records of these are kept with the daily diaries. This ensures staff are aware of the goals and maintain a record of progress and achievements. Throughout the inspection staff were observed consulted service users about what they would like to do, what they would like to eat and even if they wanted get dressed or not. One service user said they were always consulted with and provided with choices in most aspects of their live. The manager and staff said any decision about service users’ lives are always discussed with them, or if they are unable to communicate, with relatives, care managers and other professionals. This is to ensure decisions are being made in service users’ best interests. Any hazards within the home or with individuals are assessed and any action needed to minimise risks to service users is recorded. This ensures staff have the information they require to keep service users safe. Staff demonstrated a good awareness of individual risks. Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 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, & 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users benefit from respectful staff, accessing the local community, engaging in appropriate activities; and are supported in maintaining good relationships with relatives. Service users benefit from a varied and healthy diet. EVIDENCE: Staff were observed and heard being kind and respectful to service users throughout the inspection. Service users who were able confirmed that staff were “very kind”. The staff spoken with were very motivated to ensure service users were given the opportunity to go out when they wished and experience activities and social events that met their needs and wishes. These ranged from going to church each weekly, trips out to clubs in the evenings, educational groups, art & craft sessions, shopping, lunches and picnics out and many more.
Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 13 On the day of the inspection a music session was taking place with outside professionals. They said the atmosphere in the home was “lovely and staff were always nice and caring”. Service users appeared to enjoy the session. Some service users confirmed they were supported to maintain contact with family and friends. One said she phoned her sister regularly and a relative confirmed this. Service users confirmed they are offered a choice of foods and are supported to prepare and make there own breakfast and lunch. This was observed throughout the inspection. Some service users’ goals were to help prepare meals and cakes, daily records confirmed this happened regularly. The main meal of the day is not displayed on a menu for service users, but staff said that a variety of options are recorded on a sheet of paper in the kitchen and service users are given the choice of options. Service users confirmed that if they didn’t like what was on offer an alternative would be provided. The records of foods eaten showed that a healthy and varied diet is provided. Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ dignity and privacy is respected. Service users’ health needs are well met. Improvements are needed in relation to medication practices to ensure the safety of service users. EVIDENCE: The ethos and atmosphere of the home is very much about giving service users choice, respecting their rights and providing a relaxed and respectful atmosphere. Staff had a gentle, caring and respectful manner when talking about service users and when communicating with them. This was observed throughout the inspection. Service users responded well to staff and appeared relaxed and happy. A relative spoke highly of the staff team and said they were always helpful, caring and patient. Care plans described how service users preferred to be spoken to, supported and called. Care plans clearly described individuals’ health care needs and showed their needs were monitored and specialist health professionals have been regularly consulted. Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 15 All staff have received training on the safe administration of medicines. The manager is also in the process of assessing staffs’ competences to ensure what they have learnt they are putting into practice, therefore protecting service users’ welfare. Medication in both the main house and the annexe is stored appropriately. Medication is supplied in a monitored dosage system, with some boxes and liquids. Medication administration sheets were recorded correctly. One opened bottle of liquid and one tube of cream did not have the date of opening recorded. Since both medications were not used regularly it would be hard to know if the shelf life of opened medicines was appropriate without recording the day of opening. The tube of cream was also stored with medicines, which is not good practice. A “three-tiered pot” was found with medication on each tier, although there were labels describing the medication there was no explanation as to what or whom the medication was for. The manager said this was excess medication from a reducing programme that should have been returned to the pharmacy. Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Relatives and service users are assured they are listened to and complaints are dealt with appropriately. Service users are fully protected from abuse. EVIDENCE: The home has a complaints policy in a variety of formats to ensure service users, relatives and staff know how to make a complaint. Service users who were able said that they would talk to their key worker or the manager if they were unhappy. The manager has introduced service users’ meetings where issues of concern can also be raised. One service user said she would talk to her relative if she were unhappy. Staff demonstrated an excellent knowledge and understanding of Adult Protection issues. They clearly described forms of abuse, including infringing on people’s rights and choices; and knew what to do should they suspect any abuse. The home also has policies and procedures and local guidance on abuse awareness and what to if it is suspected. Some service users have their own bank accounts where some benefits are paid into. The home maintains small amounts of cash for service users’ personal spending. Good records with receipts are kept. The provider and the manager also audit these. The inspector was told that the new organisation is hoping to open and manage appropriate bank accounts for those service users without an account.
Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a clean & homely environment. Improvements are needed to some areas to protect residents’ safety. EVIDENCE: The main house and annexe are bright, clean and cheerful with a warm homely atmosphere. Service users’ bedrooms are decorated and furnished to their personal tastes and preferences. Some service users enjoyed showing the inspector their rooms. During the last inspection it was highlighted that some areas outside of the home were unsafe to service users and looked un-kept. For example, the fencing surrounding the house was broken in many places. From the outside the home was not welcoming and looked “scruffy”. The path leading up to the front door was poorly lit and was uneven. To the side of the house the concrete path and driveway was uneven. This meant that service users could not use these areas independently and staff said that the path to the front of the house was too dark to use at night. It was required that until the work to improve these areas was carried out assessments of risk had to completed with clear actions of how to reduce any risks to staff and residents. Risk assessments
Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 18 have been completed and action to reduce risks have been identified. The work to the back area of the home has been completed, with new fencing and better footpaths. The front and side of the house is to be completed soon. The time scale for completing this work has been extended to October 2006. Some radiators remain uncovered posing a risk to service users from scalds if they fall against them. The manager has completed risk assessments with details of action necessary to reduce risks while they remain uncovered, for example keeping them at a low surface temperature. The manager said there are plans to cover them very soon. The home employs a cleaner and service users help with chores when they wish. On the day of the inspection a service user was cleaning her room, changing her own bedding and doing laundry, which she said she enjoyed doing. On the day of the inspection the home was clean and free from offensive odours. Hand washing and drying facilities were available and gloves and aprons are used when necessary. Therefore protecting service users from the risk of cross infection. Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 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 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by robust recruitment procedures. Service users are supported by a trained, experienced and caring team of staff. EVIDENCE: On the day of the inspection three staff were consulted and observed. It was clear they were experienced and skilled in their knowledge of each service users’ needs, preferences and goals. In the annexe one to one and often two to one staffing is provided to ensure the complex needs of the service user can be met safely and meaningfully. Two staffs’ files were inspected and found to have the required recruitment documentation to ensure service users are fully protected. All staff have received a good range of training that helps them to understand and meet service users’ needs, the training includes, mandatory health & safety training, protection of vulnerable adults, medication administration, epilepsy, safe holding techniques and many more. Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 20 Over 50 of care staff have obtained NVQ qualifications level 2 and above. This is a national recognised qualification where staff have reached the standards of care expected in care homes. Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 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 & 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is being run in the best interests of service users. Systems to review, develop and improve the home have been developed. Service users’ safety and welfare are protected. EVIDENCE: Staff and residents spoke highly of the manager. Staff said she provided a clear sense of direction and leadership. It was clear throughout the inspection that the manager was working hard to raise standards and have better and clearer recording systems in place. For example improving care plans & risk assessments. The manager completes audits of the service through, for example care plan reviews, staff supervision and meetings, environmental and health & safety checks, audits of medication, accidents, complaints and finances. Service users
Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 22 and relatives are consulted about their views on the home and services. This quality audit ensures the home is being run efficiently and effectively and in the best interests of service users. Once a full audit has been completed the manager fills in a form with all of the findings, which is then scored and a percentage is obtained against each standard audited. The company requires action plans if an optimum score is not reached. The CSCI obtains information prior to inspections. The information includes conformation that all necessary policies and procedures are in place and are up to date. These are not inspected on the day but the information is used to help form a judgement as to whether the home has the correct policies to keep service users and staff safe. In this instance policies and procedures were in place. The fire logbook confirmed that fire safety checks, risk assessments and staff training are up to date. Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 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 3 2 3 3 X 4 X 5 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 X 4 X X 3 X Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 24 Yes 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 YA24 Regulation 23 Requirement The registered person shall having regard to the number and needs of service users ensure that (b) The premises to be used as the care home are of sound constructions and kept in a good state of repair externally and internally. (This refers to the fencing surrounding the home, the poorly lit path and the uneven surfaces outside) This is repeated from 30/03/06 This has been partly met and plans are in place to complete the work necessary to meet this requirement. Timescale for action 30/10/06 Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 25 2. YA20 13 (2) The registered person shall make 30/08/06 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (This refers to medication not being returned to the pharmacy and not being labelled with what it was or for, for a bottle and cream with no date of opening and cream being stored with medicines. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Windsor Lodge DS0000063309.V290495.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 Lodge DS0000063309.V290495.R01.S.doc Version 5.2 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!
