Inspection on 19/06/08 for Windsor Nursing Home

This inspection was carried out on 19th June 2008.

CSCI found this care home to be providing an Good service.

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

Other inspections for this house

Windsor Nursing Home 27/06/07

Windsor Nursing Home 27/07/06

Windsor Nursing Home 29/09/05

Windsor Nursing Home 28/04/05

Windsor Nursing Home 29/10/04

Windsor Nursing Home 21/07/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Windsor Nursing Home Victoria Road East Hebburn Tyne And Wear NE31 1YQ Lead Inspector Irene Bowater Key Unannounced Inspection 19th June 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windsor Nursing Home DS0000000279.V367427.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windsor Nursing Home Address Victoria Road East Hebburn Tyne And Wear NE31 1YQ 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) 0191 4301100 0191 4301100 Dr Inder Paul Vinayak Dr Veena Vinayak Manager is not yet registered. Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41), Physical disability (2) of places Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Physical Disability, Code PD, maximum number of places: 2 Old age, not falling within any other category - Code OP, maximum number of places: 41 The maximum number of service users who can be accommodated is 41 27th June 2007 2. Date of last inspection Brief Description of the Service: Windsor Nursing Home provides nursing care for people from the age of 55 years and over, and personal care, for up to 42 older people. The home is purpose built and has two floors, access between floors being with a passenger lift as well as stairs at either end of the building. There is easy access into the building and corridors and doorways are wide to accommodate wheelchairs. There is a lounge and dining room on each floor with a conservatory adjoining the rear of the ground floor lounge. The first floor lounge is the designated smoking lounge. There are 41 single rooms and 1 double room and all have en-suite toilet facilities. The home is situated between the towns of Jarrow and Hebburn and is within easy access to the local town centres and shops, and also to public transport, local parks and many other amenities. Fee rates for people needing nursing care are: £496 Fee rates for people receiving continuing care are: £534 Fee rates for people with physical disabilities are: £511.80 Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 5 The free nursing care element is included and that is set nationally. Fee rates for people needing personal care are: £395 All of these rates are weekly. Not included in the cost are personal items such as toiletries, newspapers and hair dressing. Any outing also has an individual cost. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes Before the visit: We looked at: • Information we have received since the last visit on 27 June 2007. • How the service dealt with any complaints and concerns since the last visit • Any changes to how the home is run • The provider’s view of how well they care for people • The views of people who use the service and their relatives, staff and other professionals The Visit: An unannounced visit was made on the 19 June 2008. Two inspectors arrived at 10:00 am and completed the site visit at 13: 45. During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors • Looked at information about the people who use the service and how well their needs are met • Looked at other records which must be kept • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for • Looked around the building to make sure it was clean, safe and comfortable • Checked what improvements had been made since the last visit • We told the manager what we found. What the service does well: Visitors are always welcomed and there are links with the local community. Staff are respectful and sensitive with people when helping them or when speaking to them. Staff are friendly and have a good relationship with people who use the service, families and other professionals. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 7 The home is busy and there are activities everyday if people want to join in. The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced and interesting diet. Everyone spoken to were complimentary about the food comments included: “There is always plenty to eat”. “We get lovely food”. “We can always have more if want”. Clear information is available should anyone have a concern or complaint about the care or service they are receiving. The home is clean, tidy and free from any odours. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. Staff have completed Safeguarding training so that they can recognise signs of abuse and therefore protect people from harm Staff training is good with staff having achieved NVQ level 2 or 3 so they are trained to support people in the right way. People who use the service and their relatives are able to say what they think about how the home is run which helps them to have control over their lives. Comments from surveys included: “Greatly impressed with the care A is receiving”. “All of the nurses and carers are most helpful. Nothing is a trouble to them” “I do not think they can improve at all. I am very happy with the care my relative is receiving.” “The care home has a homely feel about it. All staff to the best of their ability have a cheerful attitude to looking after the residents”. “X has only been in the home a short time and already looks much better and weight is increasing. X has been out sitting in the grounds in the nicer weather”. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? What they could do better: The assessment needs to be more detailed and cover all aspects of care including preferences, and cultural needs. There must be foot-operated bins with lids in all bathrooms, toilets and sluices. The registered persons must make sure that clean linen is stored off the floor and at a suitable reaching height. The registered provider must ensure the manager progresses with application to become registered with the Commission. The requirement from the Water Board about the shower hoses needs to be followed. The window restrictor on the upstairs landing must be replaced. One survey commented: “I feel I have to ask for information rather than it being offered.” Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 9 “Explain changes as they are put in place and not just at reviews.” 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 Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People receive adequate assessments of need, which helps them make the right decision about using the service. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which is readily available in the main entrance to the home. As the home has a new manager these were being brought up to date to show the change in manager and staffing. Everyone admitted to the home has an assessment of all their care needs, which is completed by care managers, nurse assessors and the home manager. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 12 The assessments provide information about peoples care, previous history and social activities. The assessment is being changed so that it contains more detail about preferences and cultural needs. This information is then used to complete a plan of care for the individual living in the home. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 13 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning, and access to health care services are good, demonstrating that peoples’ needs are being fully met. EVIDENCE: Since the last visit to the home the staff have continued to improve the care plans. Each person has a plan of care based on the admission information, which was carried out by care managers, the home manager and where necessary nurse assessors. Staff have completed pressure ulcer risk assessments, dependency, moving and handling, nutritional assessments using the Malnutrition Universal Screening Tool (MUST), continence and fall risk assessments. These tools help the staff understand the level of risk to people’s physical condition/health and Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 14 then forms the basis of the care plan to guide staff about how to prevent or manage the person’s care needs in those areas. Care plans showed in detail how people’s physical care needs were met. They also contained detailed information about the person’s lifestyle before they moved in; their likes and dislikes, and aspects relating to their social care needs. For example, “likes knitting”, “likes singing” and “used to play the piano”. They were up to date and showed how staff support individuals. Moving and assisting assessments specified which hoist is to be used and plans are in place for someone who becomes “overtired as can not communicate”. The plans are being reorganised so that individuals and their relatives can be more involved in the planning of care. This will make sure people have more choice about how they are looked after. Appropriate pressure relieving devices are available. Several people have air cell mattresses and cushions to prevent pressure damage. No one currently has any pressure damage. Staff involve other professionals in the provision of care. For example, weights are regularly recorded and should there be weight loss or difficulty with eating or drinking, a referral is made to the GP and to speech and language therapists (SALT team). Advice is also sought from, occupational therapists, GP’s, and continence advisors and visits from the multi disciplinary team are recorded in individual care plans. This ensures that the right advice and guidance is provided by specialists to help the staff meet people’s diverse range of needs properly. All of the staff had a good understanding of individual needs and were alert to changes in people’s mood and made sure that support and assistance was given in a discreet sensitive manner. The home has policies and procedures to make sure staff administer all medicines safely. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities to take part in meaningful activities and keep control of everyday decisions are good. This helps to ensure that people are given the opportunity to lead full and active lives. EVIDENCE: The home benefits from an enthusiastic activities person who organised events both inside and out of the home. Events are displayed and include, bingo, dominoes, arts and crafts, pamper days, sing a longs and quizzes. Some people attend “The Happy Circle” which is a group that meets weekly in the evening at the local church. Lay preachers from the Roman Catholic Church visit the home on a regular basis and visit anyone who wishes to see them. Should anyone have any other faith or denomination the home would make provision so that this could be met. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 16 There is an excellent choice of activities and most people join in. Some people prefer to stay in their rooms and the staff team respects this. The lounge was busy. Everyone was enjoying answering a quiz playing bingo and dominoes. There has just been a sponsored wheelchair push to the local pub, which was greatly enjoyed. The staff were sensitive and showed interest in what people were doing. For example one person said, “what did you do this morning? Did you win the bingo? What twice! You’ll be getting banned”. Other staff said, “do you want the music up a bit or turned down”? And, “Where do you want to sit now”? And, “is it too early for you to go to the dining room”. People living at the home said they were happy. Comments included: “Its good here” “We have a laugh” “Plenty to do to fill the day if you want it” “I basically do what I like” Visitors are welcome at any time and information about advocacy services are available in reception. Many people have brought small items with them making their rooms homely and reflective of their lives before they moved in, their religious beliefs and cultural backgrounds if they wanted to. There are dining rooms on each floor. The tables were set with cloths, cutlery crockery and condiments. Food is prepared in the main kitchen and then served from a “hot lock.” The cook served the meal. Further thought could be given to introduce some self-service so that people could retain their independence. Choices were cottage pie or corned beef pie with two vegetables and potatoes. There were also various choices for dessert and hot and cold drinks were available. Staff sat with people who needed help and this was given in a discreet and sensitive way. Menus are changes regularly and the cook talks to everyone to make sure they like what is on the menu. Comments about the food were good: “Good food” “You get plenty” “I have seconds” Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good complaints and protection procedures are in place to ensure that people and their relatives are listened to and protected from abuse. EVIDENCE: The home has a complaints policy and procedure, which is easy to understand. It is in the Service User Guide and displayed in the reception area of the home. The complaints book records all concerns with action and outcomes to prevent complaints from recurring. Since July 2007 there have been six complaints five of which have been resolved at home. The Commission received one complaint, which was then referred to the Safeguarding Team. This was resolved to everyone’s satisfaction. Staff are trained in Safeguarding Adults procedures so can recognise abusive situations and would know what to do if they suspected abuse. There is also written information and guidance available in the home for staff to look at it if they need further guidance. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being well maintained, is a pleasant, clean and comfortable place for people to live. EVIDENCE: The home has two floors each having bedrooms, bathrooms, toilets and communal lounges and dining rooms. There is also access to a pleasant garden and there are plans to have a water feature and bandstand added in the near future. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 19 Since the last inspection new furniture has been provided and there is an ongoing replacement and redecoration programme to improve the overall standard of accommodation offered. The corridor upstairs has been redecoration in neutral colours, as have the bedrooms. A window restrictor on the first floor landing was not in place to prevent any possibility of someone falling out. New lounge furniture and carpets have been ordered for the downstairs lounge. All of the bathrooms and shower facilities are in working order and a specialist bath seat is provided in a downstairs bathroom. However, another bathroom, opposite room 12 had a blue seat, which was full of dust, and most of the bathrooms and toilets including the sluice did not have foot-operated bins with lids. These are needed to reduce the risk of cross infection. All bedrooms have an en-suite toilet and washbasin. Bedrooms have been redecorated and people have been encouraged to bring small items with them, making their own rooms highly personalised and reflective of their lifestyles. The laundry is small but clean and organised. But the linen cupboard was cluttered and untidy with bedding and other line stacked nearly to ceiling height, with some linen stored on the floor. On the day of the visit the home was clean tidy and free from any odour. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels and systems around recruitment, selection and training of staff meet the range of needs of the people using the service and protect them from harm. EVIDENCE: The home now has a new manager who has yet to be registered with the Commission. She is currently completing supervision sessions with all staff so that their training and development needs can be identified. On the day of the visit the home had twenty-three people living there. Fifteen people need nursing care and eight receive personal and social care only. Should they need any nursing input this is provided by the district nurse. There is one qualified general nurse on duty over twenty hour hours with five carers in the morning, four in the afternoon and evening and three overnight. These levels currently meet people’s needs. However the staffing levels will need to be reviewed when occupancy levels increase. The home also employs an activities person, administrator, cook, kitchen assistants domestic and laundry staff and a maintenance person. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 21 The records for recruitment were satisfactory. There was evidence of Criminal Record Bureau checks, Safeguarding Adult checks, two written references, proof of identity and professional identity numbers for registered nurses to ensure that suitable people are employed. New staff have an induction period, which sets out clear standards about all areas of care and employment. And mandatory training for moving and handling, fire prevention, first aid, safeguarding adults, and infection control and food hygiene are also up to date. A training and development plan has been put in place and includes, communication and the older person, person centred care planning immunisation update and continence care. One member of staff is currently completing a Palliative Care Course and has completed training in Liverpool Care Pathways. All care staff have either National Vocational Qualifications (NVQ) level 2 or 3 and more staff are planning to complete NVQ level 3, which, is above the National Minimum Standard. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is good. And quality assurance systems are in place, which makes sure people receive a good quality of care. EVIDENCE: There is a new manager in post who has yet to be registered with the Commission. She is a first level nurse with many years of experience in care of older people. In addition, she has experience as a deputy manager for five years and has completed a Diploma in Dementia Care. She is to complete the Registered Managers Award. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 23 Since she took up post she has begun regular staff meetings to discuss any issue they may have and to let them know how the home is going to develop in the future. There are also regular relative and resident meetings, so that they also know what is happening in the home. The manager says there is “an open door policy.” Staff and people living in the home said the new manager was approachable and would discuss any issue with them. The manager has also started two monthly supervisions for all staff, where she can discuss performance, workload and development issues with staff in a one to one session. Quality assurance and monitoring systems have started. Care plans are audited three monthly, medication, infection control practices and environmental audits are being completed monthly. Relatives are being asked to complete questionnaires so that the manager can have a clear understanding of how they view the home and use the information to plan improvements. The AQQA was completed and the information gave a reasonable picture of what was happening in the home. Further detail would show how they plan to improve over the next year. Records of personal money kept on behalf of individuals were looked at. Information is held in a bound, hard backed book. Clear information is available about all expenditure which can bee cross referenced to receipts. A check of three people’s money found no discrepancies. All internal maintenance records and external certificates are up to date. Fire training was completed in May 2008 and a Fire Prevention inspection was completed in November 2007.The requirement to put a door between the laundry and bedrooms has been done. And staff have completed training in safe working practices. Accidents are recorded and there is a monthly analysis to monitor and track trends. Risk assessments for safe practices including use of bedrails are in place and up to date. When looking through the records the requirement from Northumbria Water Boards visit had not been actioned. This was to make sure that shower hoses are kept out of bath water and prevent risk of infection Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 24 Individual risk assessments need to be in place should anyone wish to store Steradent tablets in their rooms as this has been identified as a possible risk Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement The registered persons must ensure that the assessment covers all aspects of care including preferences, and cultural needs. The registered persons must remove the blue chair from the bathroom. The registered persons must ensue that there are footoperated bins with lids in all bathrooms, toilets and sluices. The registered persons must make sure that clean linen is stored off the floor and at adequate reaching height. The registered provider must ensure the manager progresses with application to become registered with the Commission. The registered persons must ensure that risk assessments are available for the use of Steradent. The registered persons must Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 27 Timescale for action 01/10/08 2 OP26 13,16,23 01/08/08 3 OP31 9 01/10/08 4 OP38 23 01/08/08 follow the requirements of the Water Board regarding shower hoses. The window restrictor on the upstairs landing must be replaced, 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 Refer to Standard OP15 Good Practice Recommendations It is recommended that daily menus be put on the dining tables so people can see what is available for each meal. It is also recommended that consideration is given to provision of tureens so that people can self serve their meals. Windsor Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Nursing Home DS0000000279.V367427.R01.S.doc Version 5.2 Page 29 - 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. 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