Inspection on 27/06/07 for Windsor Nursing Home

This inspection was carried out on 27th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 19/06/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Windsor Nursing Home Victoria Road East Hebburn Tyne And Wear NE31 1YQ Lead Inspector Mr Tom Moody Key Unannounced Inspection 09:30 27 & 29th June 2007 th 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.V340412.R02.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.V340412.R02.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 Position Vacant Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42), Physical disability (2) of places Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service may from time to time admit persons under the age of 65 within the OP category 27th July 2006 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 but one single room, 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. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, and was carried out by one Inspector over 3 days in June 2007. An immediate requirement was issued and this was met by the proprietor within 48 hours. Before the inspection a self-assessment questionnaire had been completed by the Manager, which gave up to date information about the home to allow more time to be spent with residents on the day of the inspection. A tour around the home to check the cleanliness, health and safety matters, and maintenance and decoration was carried out. The inspector spoke with residents, visiting relatives, and staff including the cook, and the Deputy Manager. The inspector did not have lunch with residents but observed the meal that was served in the two dining rooms. A number of records and documents were examined including residents’ care plans and staff files. What the service does well: The home has a very friendly atmosphere, which residents and visiting relatives informed the Inspector, was always the case. All visitors to the home were made welcome and treated with courtesy and respect by the staff. Some staff in the home have a good knowledge of service user’s needs. A number of staff employed have worked at the home for a considerable time. and provide consistency and continuity of care to the residents. All care staff have completed NVQ training and wear badges to display this on their uniform. Residents and visiting relatives spoke well of the staff. Comments such as, “It fells good it’s as good as home.” and “the staff are good lasses”, were typical of those made to the inspector. Meals are varied and choices and alternatives are available. The residents enjoy ‘home style’ cooked foods and they were very complimentary about the quality of foods served, one said “the grub is good”. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 6 The kitchen staff are equally enthusiastic about their role and the service they provide. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Service users entering the home have most of the information they need and their needs accurately assessed by social care and health service staff. The home makes it’s own assessment in addition to this but this must be improved. EVIDENCE: The providers self-assessment states that a copy of the service users guide is available in the lobby and that this contains all of the necessary information to meet this standard. At the time of the site visit some of the information was out of date and this needs to be revised. The provider states that assessments are carried out and that no one is admitted unless the home is confident it can meet their needs. It also states that service users can make trial visits to the home. The nurse in charge confirmed that relatives and SU can visit as often as they wish before deciding Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 9 if they want to be placed in the home. Service users did say that their relatives were able to visit the home and make the decision for them to be placed there The last inspection report outlined weaknesses in assessment of needs but the provider’s say they are revising the pre-admission assessment form to improve this. The care plans seen were improved and the assessment of service users needs were still problematic. Although the physical needs of service users were planned in a mechanisitic, and rather old fashioned, way the psychological needs of some service users were still not being addressed. Service users contracts were seen and did contain necessary information. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Service users physical health care needs are being met but other areas, such as risk assessment and psychological needs are deficient. Service users have access to most of the healthcare services that they need. The home has appropriate policies and procedures to ensure service users receive their medication in a safe way. EVIDENCE: The provider’s self-assessment indicates care plans contain good clinical information, and cite inspection report as a source for this, but the last inspection noted the organisation of this was haphazard and recording of psychological needs and communications strategies were poor. The selfassessment does speak of some care plans being “muddled” and that some risk assessments have not been completed regularly. This was confirmed during the site visit. The service user’s care plans contain much clinical information but they showed no structure or relevance to any models of care and looked very dated. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 11 Moving and handling assessments were equally vague and simply specified the number of staff to be present without indicating any strategy. Most moving and handling practice that was observed was satisfactory but I observed one service user was lifted using a “drag lift” i.e. suspended by their arms between two staff. On another occasion it was seen that a hoist did not go low enough for the service user to reach their chair. Staff had to take the weight of the sling to complete this maneuver and this could put both staff and service users at risk. Some service user’s at risk of pressure damage had no mention of any pressure relieving aids (although they had been deployed within 3 days). The poor standard of record keeping, by qualified staff, could have serious consequences for them in terms of their professional accountability. The assessment of needs for bed rails was badly designed and ill informed. Bed rails had been deployed for service users where there were clear risk factors present. This information was readily available to staff, on a chart outlining the hazards, however, it seems to have been disregarded. An immediate requirement notice was issued in relation to this hazard and the provider rectified the problems withing the 48 hours specified. Self-assessment states the controlled drug storage is now “adequate”. At the time of the site visit the Nurse in charge confirmed that there is an appropriate system for disposal of unwanted drugs. The storage of medication has improved. The clinical area was at a more appropriate temperature. The controlled drug storage is appropriate. A monitored dosage system is in use and recording is good. Stock balances are correctly kept. The home state that they do involve clinical specialists and the service users do have access to health services and there is a record of visiting professionals in service users care plan . There have been 6 deaths in the home since the last inspection. This is not unexpected or unreasonable given the high dependency, age and frailty of the client group. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The homes staff endeavour to provide a lifestyle that matches service users needs and preferences. Meals are of good quality and the timing and choice can be varied to meet service users needs. EVIDENCE: The providers self-assessment states that the activities that are provided are appropriate to the service users age group, and this includes provision for younger service users. Activities outside the home take place and there is contact from ministers of religion. The assessment does acknowledge that better assessment of social needs should be made. It does say that staff are welcoming, that they work hard at developing relationships with service users and families and that the home has an “open door” policy. The provider has an activities co-ordinator who is enthusiastic about her role and they state that the quality and presentation of food is good. The home acknowledges that giving medication at the same time as food detracts from the dining experience and that some staff have to be reminded to sit with service users who are being assisted. The home also feel they could make more use of advocacy services. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 13 I observed that staff deal with relatives, and telephone enquiries, appropriately and have a good relationship with famillies. The cook makes regular contact with SU to monitor satisfaction with the meals. I saw the cook asking service user’s preferences and one service user said of her that, “She keeps me going with her curries.” Other service users spoke favourably about the quality of food. Kitchen staff are obviously kean and well motivated. Menus are satisfactory and the kitchen staff have list of service users choices. The kitchen is clean, well organised and it is well equipped. The quality and presentation of food was good. Service users were supported in a suitable manner by staff. Visiting is unrestricted and visitors were seen coming and going throughout the day. Several service users confirmed they were able to go into to the garden if the weather was suitable, one said, “It’s a regular Sun trap.”. Staff adressed service users appropriately and they are enthusiastic about their role.Some staff display a good depth of knowledge of service users needs. All service users who were spoken to expressed positive views on the way they were looked after. Typical coments were, I can get up when I want and I can go out when I want to, The staff are all very good. Relatives were equally complimentary about the care in the home. One service user did say that, “Sometimes the music gets boring. I like big bands and we don’t have any of those records.” This is something the home could pursue in terms of service user choice. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home has appropriate policies and procedures, and recording is good. Service users and the majority of relatives are confident in the process and how staff will operate it. This should ensure the protection of service users. EVIDENCE: The provider’s self-assessment indicates that the homes complaints policy is prominently displayed and that all complaints are recorded, although previous reports have noted few recorded complaints. They are also confident staff have a good awareness of adult protections issues and that there is an appropriate whistle-blowing policy. The home acknowledges that formal auditing of service user finances needs to take place, advocacy services could be used and that more work needs to be done on recording complaints, in spite of recent improvements. There have been 3 complaints recorded since the last inspection and these were dealt with within the time scale given in the home’s policy. The records in the home indicate that there has been an improvement in the level of recording since the last inspection. Outcomes are also usually recorded for this. The nurse in charge states that relative groups meetings take place. The manager also stated the home had an open door policy. All relatives who were spoken to said that they found the staff helpful and felt that the new manager was approachable. Staff spoke of having training in adult protection and had a good awareness of the issues surrounding this. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 15 Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 16 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): Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The environment is maintained in more public areas but some areas still need attention and these are outstanding from previous reports. Similarly, the home has some good equipment but there are some areas that are deficient. Therefore, although the home is, in the main, safe, some hazards are present and need to be eliminated to ensure service user’s, and staff’s, safety. EVIDENCE: The home is relatively modern and purpose built., unfortunately it is not clear that it is being maintained as well as it should be. The homes self-assessment indicates that all maintenance and checks are carried out and recorded. It states that the home has suitable facilities for disabilities and a loop system is in place. There is a programme of replacement of fabrics and soft furnishing. The provider also states the problem of low light levels has been addressed and the home is now odour-free. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 17 At the site visit this was found to be inaccurate in relation to light levels. Lounges had good levels of natural light and were well ventilated. The lobby area is well decorated but the level of décor varies throughout the home and more distant areas are looking worn. Most service users bedrooms contained personal items and were pleasantly decorated. The decoration in the bathrooms has been improved. However, as noted in the last report, the bath panels were damaged in one area. The nurse in charge confirmed this room is not usable for the majority of service users because it does not contain a hoist. The upstairs shower room was out of use. This was apparently due to water leaking into the floor below. There is a jaccuzzi type bath but staff say that this is not used because of the problems of sterilising the bath after use. It seemed that at least three of the bathing facilities were not available to service users because of these problems. In addition to this, the underside of one of the bath-hoist seats was badly stained. This was pointed out to the person in charge. Although light levels have been improved in some areas the corridors of the home are still not properly lit. Light levels in corridors are so poor that it is difficult to read documents at the nurses station. This is uncomfortable and hazardous to staff and a potential hazard from mis-reading documentation. Light from service user’s room-windows, throws strong bars of contrast across the corridors, in spite of the lights being on. It was pointed out in the last inspection report that this could put service users at risk of falls or disorientation, and that light levels should be maintained at 150 Lux, as stipulated in National Minimum Standards. This was brought to the staff’s attention on the day. The walls, skirtings and doors in corridors have suffered considerable impact damage from wheelchairs. This is especially so on the upper floor. There is a leaking radiator opposite the nurses station and the staining on pipes suggest this is not just a recent problem. This has made the carpet damp in this area. The home has moving and handling equipment, but a greater variety needs to be deployed. As outlined in the section on Health and Personal Care, some hoist do not permit safe moving and handling, due to limitations in travel, or not being matched to the furniture in the home. Fire precautions were observed by staff. The home was kept clean in most areas and there were no unpleasant odours detected in areas occupied by service users. The home has a sheltered and secure garden area that service users were able to use. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The home has sufficient numbers of staff to meet service users needs. Recruitment procedures need to be improved to ensure service users are looked after safely. EVIDENCE: The provider’s self-assessment acknowledges there have been “shortages” in registered nurses at times. The document does say that all of the nurses are well trained and experienced and that cover can be provided by them to avoid the use of agency nurses. The provider’s information indicates only 16 of staff have NVQ level2, however, this is an error and there is 100 attainment of this standard. The manager did confirm she had to spend some time in a caring role due to staf frecruitment difficulties. This had been rectified but she said that this had slowed the rate at which she could make improvements as a manager. The duty rotas indicate a satisfactory level of staffing is available . At the time of the site visit staff did not appear to be unduly pressured and the call system was answered promptly. The recruitment records seen at this inspection indicated that not all necessary checks have been carried out. Some references do not make the status of the referee clear and there is no proof that it is a person of any standing. Some of the training records have been retained from previous employers. The ammount of “training” apparently received in the course of one day is not Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 19 credible and it must be doubtfull if this can be relied upon. This should have been queried during recruitment. There is documentary evidence of staff training, and staff confiirm they receive good induction and support. Staff members were wearing badges that indicated they had attained NVQ qualifications. Service users and their relatives comments showed they were satisfied with the way they were looked after. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 20 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): Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The manager is professional in her approach but has had little time to make an impact on the home. Service users benefit from the way she carries out her duties. The home needs further support, and resource, from the registered owners to ensure the home provides a suitable environment for service users and staff. EVIDENCE: The providers self-assessment acknowledges recent management changes and says this has created an obstacle to progress. However, it also indicates the manager has been supported by the proprietor. Self-assessment states the home is appropriately insured. Occupancy has been low, but there has been a marketing strategy put in place. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 21 Self-assessment indicates they hold regular meetings with service users and relatives. Changes are made in response to this and menu changes were given as an example. Self-assessment indicates supervision takes lace for staff. The home have put up a suggestion box and the self-assessment indicates there is a monthly quality assurance audit that takes service users views into account. The self-assessment indicates that policies and procedures have not been reviewed since 2004/5 and this should be looked at. The new manager is not yet registered with CSCI but she has completed the registered Managers Award. She has management experience in the care sector. The manager was not in the home at the time of the first site visit although she was seen in a follow up two days later. Most of the fabric of the home was safe, apart from the low light levels, lack of maintenance in some areas, and the deployment of unsuitable bed rails. Risk assessments were carried out but the manager must ensure these are meaningfull and that they acurately predict risk. There was evidence that the manager was already improving some of these at the time of the follow up visit and the prompt response to the immediate requirement was helpful. Service users and their relatives spoke of staff and managers being approachable and all of them indicated they could take problems to the manager (although most were at pains to point out they were satisfied with the home). The manager spoke of supervision being carried out and records confirmed this. Discussions with the staff revealed thay are well motivated and enthusiastic about their job. The manager has not yet adopted a quality assurance system and it was suggested that a simple system should be adopted. Service users financial records were seen and the system is fairly robust. receipts are kept and balances are checked regularly by two people. It was recommended at the time of the last inspection that both signed for this. Accumulated balances are placed in a pooled account and this is not in line with National Minimum Standards even though it is not interest bearing. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 22 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 2 3 2 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 2 2 2 3 3 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 2 2 3 2 2 Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 23 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 OP1 Regulation Requirement Timescale for action 19/08/07 Regulation Information in the service users 4(1) (2) guide must be accurate and up to date. 15(1) (2) There must be a suitable care plan drawn up to ensure service users needs are being met and to maintain the accountability of staff. (This remains an outstanding requirement from previous reports) An accurate assessment of risk must be carried out in relation to care strategies, such as moving and handling, or deployment of equipment, such as bed-rails. All areas of the home used by service users must be adequately decorated and maintained. (This is an outstanding requirement from the previous report) Light levels, in all areas occupied by service users must be maintained at the specified minimum of 150 Lux. (This is an outstanding DS0000000279.V340412.R02.S.doc 2. OP7 19/08/07 3 OP3 OP38 13(4)(a) (c) 19/08/07 4. OP19 23(2)(d) 23(2)(b) 19/09/07 5 OP25 23(2)(p) 19/09/07 Windsor Nursing Home Version 5.2 Page 24 6. OP21 23(1)(a) 23(2)(c) 23(2)(j) requirement from the previous report) Adequate number of bathing 19/09/07 facilities, suitable to meet service user’s needs, must be maintained in the home. (This is an outstanding requirement from the previous report) The home must provide equipment, such hoists, bedrails and suitable bathing facilities, to meet the assessed needs of service users. (This is an outstanding requirement from the previous report) All necessary recruitment checks must be carried out to ensure service users are protected. The manager must ensure that all aspects of health and safety in the home are accurately assessed, documented and dealt with promptly. 19/09/07 7. OP22 23(1)(a)2 3(2)(n) 8. OP29 19(1)(b) (c) 12(1) (a) 12(2) 19/08/07 9. OP38 19/08/07 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 OP14 Good Practice Recommendations The home should ensure personal choice is ascertained when music or other entertainments are offered. Windsor Nursing Home DS0000000279.V340412.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South Shields Area Office 4th Floor 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.V340412.R02.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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