Inspection on 05/09/06 for Windsor Residential Care Home

This inspection was carried out on 5th September 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 25 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Windsor Residential Care Home 23/05/08

Windsor Residential Care Home 30/05/07

Windsor Residential Care Home 23/12/05

Windsor Residential Care Home 06/05/05

Windsor Residential Care Home 16/08/04

Windsor Residential Care Home 16/04/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Windsor Residential Care Home 18-20 St Mildreds Road Westgate-on-sea Kent CT8 8RE Lead Inspector Clair Brown Key Unannounced Inspection 5 September 2006 11:20 th Windsor Residential Care Home DS0000023628.V305142.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 Residential Care Home DS0000023628.V305142.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 Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windsor Residential Care Home Address 18-20 St Mildreds Road Westgate-on-sea Kent CT8 8RE 01843 836055 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) info@craegmoor.co.uk Parkcare Homes Limited Carole Saunders Care Home 17 Category(ies) of Learning disability (17) registration, with number of places Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Windsor Residential Care Home is registered to provide residential care for up to 17 adults with learning disabilities. At present there is no identified upper age limit. The Home is owned by a large company and has a Manager who is responsible for the day-to -day running of the establishment. Windsor is situated in a residential area of Westgate, which is adjacent to the seaside town of Margate. The Home, which has a small front garden, is within walking distance of most local amenities, including the seafront and local shops. There is limited off road parking but there is on road parking to the front of the property. There are staff on duty 24 hours a day including staff on wake duty at night. The health care needs of the residents are met by the local primary health care team. The fees are from: £ 851.00 - £946.00 per week. Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection consisted of an unannounced visit to the home on 5th September by one inspector. The inspection takes account of information received from a variety of sources including written information from the registered providers, service users, staff and general practitioners. The previously made requirements and recommendation from other inspections were inspected and all key standards. Comment cards were completed by 8 service users & 1 GP. The inspector spent time talking to service users and the care staff to gain their views. A tour of the premises was conducted. Documents and records were seen and service users files were case tracked. What the service does well: What has improved since the last inspection? What they could do better: The care plans need to include all of the service users needs and the relevant health needs assessments and these must be regularly reviewed. Staff need to start using these documents and referring to them on a regular basis. Confidential information needs to be recorded and stored appropriately. The provision of the appropriate equipment and improvements in practices relating to the administrating of medicines is needed. Staff training needs to provide them with the knowledge and skills for their position, to be taught by those competent to do so, regularly updated and staff need to then put in to practice what they have learned. Some areas of the home are in need of refurbishment and action is needed to resolve the offensive odours in some areas of the home. Recruitment procedures need to include an interview record and the registered manager needs to ensure those that require work permits have the appropriate paperwork. The care staff need regular formal supervision and Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 6 should take on the full responsibilities of their role. The registered manager needs to be supported by those in senior care positions to enable her to fulfil the responsibilities of her position. The homes quality assurance programme should be expanded to include the views of those who live at the home and are closely involved with the home. Fire procedures need to be more vigorous and all staff need to attend fire drill. 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 Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 7 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 Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 8 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): 125 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose does not provide service users with up to date information. The contract fails to provide service users with clear details of the terms and conditions of living at the home and what services they will receive. Assessment tools are available to assess the needs of prospective service users. EVIDENCE: The statement of purpose has not been updated since the changes within the registered company. The service user contract seen in their files, fails to inform them of their rights and what services the home provides for the fees paid and what is not included in the fees and nothing about the termination of contract and trial period. At the time of the visit no new service users had been admitted, therefore there were no pre-admission assessments completed to assess. One service user is currently in hospital following a fall and will require a full assessment before returning to the home, the registered manager demonstrated that she had prepared the relevant documentation to conduct this assessment. Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 9 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 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning system is inconsistent and does not adequately provide staff with the information they need to satisfactorily meet service users needs. Service users are only involved in some of the decision making about their routines & care. Confidential information is not stored & recorded appropriately. EVIDENCE: One service user file was case-tracked, found the care plan was originally written in 2004, reviewed 11/05 and some sections of the care plan have been written 04.06. The service user has seizures and care plan states to record them but nothing about action to take in the event of a seizure. No evidence found of record being kept of the seizure, when discussed with the registered manager she stated that was because the service user hasn’t had a seizure for a long time. The care plan covered a variety of needs but these were out of date, specialist shoes ordered in 2004, no records as to whether or not they have them or information about wearing them. The nutritional assessment Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 10 was not dated, incomplete and not cross-referenced to care plan. The last weight recorded in 02.05 and the service user had previously lost over a stone in weight. A significant number of the service users have restricted mobility and use wheelchairs, the skin integrity assessment tool had been altered and this affects how the score is produced therefore is an unproven format. Daily reports vary in the quality of records, some records are fairly detailed, others are very brief and not always personal to the individual or relating to the care plan. Some staff use phrases such as “slept well, no problems”. The registered manager stated that other care plans have been rewritten and these are detailed and provide pinpoint details on meeting care needs. Care staff confirmed they do not refer to the care plans when working. The home uses communal documents called Handover sheets, these include service users names and confidential information, this practice breaches data protection rights. Three service users surveys stated that they are always able to make decision about what they do each day, however four stated that this is only sometimes. Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 11 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): 11 12 13 14 15 16 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported to participate in activities of their choice and to attend further education. A nutritious and varied diet is provided but not supported by regular assessments and records. EVIDENCE: The age of the service users has an impact on the range of activities available and providing those appropriate to their age. Some service users have individual timetables for their daily activities and others are generally available to all, these include Music Man, Exercise for All, attending college and day centre. Service users are also supported to develop independent living skills, by using the skills kitchen for learning to make drinks, cooking meals and washing their clothes. The service users receive only £100 towards their week’s annual holiday from the company. The cook was able to demonstrate that the home provides for those with special dietary needs, however the cook has not completed any formal training in this area. Other training courses the cook has attended need updating such as basic food hygiene. The main kitchen and the service users skills kitchen are in need of refurbishment, they Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 12 are tired and worn, the flooring in one is cracked. There was a discussion about the need for more kitchen equipment such as saucepans. No records of individual meals provided are kept. Breakfast can include a cooked breakfast if desired, at lunchtime the main meal is served, the menu shows that there is always a minimum of two hot options, mid afternoon there is cake and crumpets etc, tea is also a hot meal such as sausage rolls, Cornish pasties, supper consists of scones, sandwiches, etc. Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. There is a failure to ensure that health needs are assessed and up to date. Medications practices potentially place service users at risk. Limited provision is made for the care needs of the ageing service users. EVIDENCE: The service users ages range from mid 30’s to late 70’s, with only 3 being in their 30’s and most of the remainder being 50 plus, of which 7 are 60 plus. Although some provision is made for the ageing of the service users it is currently inadequate taking into consideration the fact that a significant number of the service users are elderly and already experiencing the effects of this. Under section “individual choice & needs” of this report are the details of some of the evidence in relation to the meeting of health needs, including the lack of up to date health assessments such as nutritional and skin integrity. There are some records relating to accessing health care professionals when need, however these records are vague and need to provide details of action taken and any follow up needed and then be cross referenced to the care plan. The GP survey raised no concerns and commented on how good the home is at getting the service users to the surgery despite their disabilities. Six out of Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 14 the eight service users surveys stated that staff listen to them and act upon what they say. A Medication audit was conducted with a senior member of care staff, there is a designated medication room that also is used as an office by staff. The room does not have a hand-wash basin and no work surface to place medication & records on. The home does not have a medication trolley and concerns are raised over the safe transportation of medicines to the service user. There is some evidence that the same prescribed medicines are being shared between service users, also some medicines prescription label instructions reads “use as directed”, therefore not providing staff with clear instructions on dose etc. The records of receipt of medicines are not dated. Creams & tablets stored together on the same shelf. No records of the medication fridge temperatures are kept. Other records assessed relating to medication showed little evidence of errors. Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are confident that their concerns will be listened to and acted upon. Staffs has not gained sufficient understanding of adult protection. EVIDENCE: All eight of the service users stated in their surveys that they knew who to speak to if they were not happy, although only five knew how to make a complaint. Records of complaints made directly to the home, showed that these were fully investigated, although consideration should be given to who is the appropriate person to conduct the investigation if the complaint is directly related to a person employed at the home, for example the registered manager investigating a complaint which implicates themselves. Although staff have attended in house adult protection training they were unclear of adult protection procedures and the processes for reporting allegations, most said they would report it to the manager and the company, only one was aware of need to inform social services and its role. Service users monies are held in a designated service user bank account, which is overseen by the company, service users are not provided with copies of their bank statements but given transcripts drawn up by the company. Service users do not have direct access to their money in the bank but the home has a company credit card, which is used to make purchases on behalf of the service users. Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 16 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 25 26 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. The lack of a maintenance programme fails to ensure the building and furniture is maintained to a satisfactory standard throughout. Areas that have been refurbished have been done well. The home has offensive odours in multiple areas of the home. EVIDENCE: There is no formal annual maintenance programme in place. The registered manager does have a list of maintenance work that needs attention. Despite holding a budget the registered manager requires permission from the company/owner to refurbished areas such as bedrooms and for major repair jobs. The home shares a maintenance person with another home and this causes delays in work being carried out. One example of this is that a fault with the emergency lighting system had not been attended for nearly a month. Areas of the home that have been refurbished are pleasant and personal and are in contrast to those that have not been done. One bedroom has had a water leak, on the wall was mildew and the wallpaper was peeling off of the Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 17 wall. The registered manager did arrange for immediate action to be taken regarding the removal of the mildew. Two of the shared bedrooms are below 16sqm and therefore too small to be used as a double rooms. A number of the bedrooms have odour management problems, although there is proposed action in planned to deal with the most severe of the cases. In general the home was clean, however some service users surveys state that this is not always the situation. Infection control procedures require improving and appropriate equipment for disposal of clinical waste needs to be provided such as foot operated pedal bins. The kitchens looks tired and well used. The home has a second kitchen area, which would benefit from some refurbishment, this kitchen is used to support service users in developing independent living skills, cooking meals, preparing drinks etc. Some service users are supported to hold their keys to their bedrooms. Four service users require wheelchairs and hoists for mobility and transfers, to date only one adapted bathroom has been installed but the registered manager stated that it has been agreed to convert another bathroom. Some areas of the home have undergone refurbishment, these rooms were pleasantly decorated and furnished, the design and décor was personal and individual in bedrooms and communal areas that had been refurbished, were modern and had the feel of a private residence. Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 18 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 33 34 35 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number of care staff provided needs reviewing. Insufficient numbers of the care staff have completed the required NVQ training. Staff are not implementing the knowledge provided through training. Recruitment procedures are adequate but need some improvement. Staff are not adequately supported through formal supervision. EVIDENCE: The registered manager does not have dependency tool to calculate the levels of needs of the service user to then assist with the processes for calculating staffing levels. The home is able to use agency staff if needed but prefers to try and cover gaps in the staffing with their own staff. There is between 4&5 care staff on duty during the day, Monday to Friday they are supported by domestics and a cook. At the weekends they are required to cover these duties. At night there are two waking night staff whose breaks are paid. The registered manager needs to give added consideration to the staffing levels in relation to the needs of the service users who are elderly and those who require two or more carers to meet their needs, such as transferring with hoist, personal care, etc. At the time of the inspection visit none of the care staff have completed the NVQ level 2 in care training, currently only 6 of the 15 care staff are enrolled on the course. The care staff demonstrated a lack of Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 19 understanding about the regulation of the home when they spoke with the inspector, (including the National Minimum Standards) and the provider reports and the registered manager provided evidence that care staff are reluctant to take on roles relevant to their position such as writing the care plans. Two staff that had been employed between a year and 18 months had not completed their induction programme, another member of staff had not started the induction programme. The training matrix shows the mandatory subjects but there is no training provided relating to caring for those with Learning Disabilities. The Pre-Inspection questionnaire states that a variety of training courses have been undertaken by the home over the last 12 months, the majority of which is the registered companies/providers own training programmes which is then taught by the managers of the home. The registered manager does not have any form of teaching certificate and was not able to confirm that the training programmes have been verified. The registered manager was aware of the need to provide training relating to the needs of the elderly but the company does not provide any relevant course and so she is now looking at other sectors to locate the appropriate training. The recruitment procedures do not include an interview record, although staff do have a POVA first check before starting work, this needs to be supported with the newly recruited person being supervised at all times and this to be identified on the duty rota. The home has not contacted the Home Office for clarification about staff employed with work permits. All other required employment records were seen to be obtained. The formal supervision of staff has not been occurring as frequently required. Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 20 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 38 39 41 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager has the appropriate skills and qualification to meet the demands of the role, however there is limited support from within the home and this has impacted on the day-to-day and long-term management of the home. The home has only a limited quality assurance programme. The majority of the environmental health & safety checks are satisfactory, however fire procedures need to improve. EVIDENCE: The registered manager has successfully completed the Registered Manager Award earlier this year. The registered manager was aware of a number of the issues identified during the course of the inspection visit, but has found herself stretched for time and support, as she has not been able to delegate some duties to the deputy manager as she would normally as the deputy manager has been on maternity leave for the least 6 months. Care staff spoken with who worked at the home before the manager changed 2 years ago speak Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 21 highly of the registered manager and they can see the improvements in the home. One carer shared that previously they had been told not to tell the inspector anything therefore was frightened of inspections, they said they had been encouraged to be involved this time and the registered manager had actively encouraged them to speak to the inspector, the carer found the process useful, a learning experience and has dispelled a lot of fears about inspections. Environmental certificates were seen to be in date. Fire records show that the fire brigade made requirements in April 2006, including two faults with the emergency lighting, at the time of this inspection visit this fault had not been repaired. There were also gaps in the frequency of the fire safety checks and no records of staff being involved in fire drills/instruction. The hot water temperature records could not be located and the registered manager stated these are only tested monthly. The health & safety poster is out of date. The insurance certificates was seen to be in date. A selection of in house audits are conducted, including medication and financial. The main audit/ quality assurance programme has been completed and is a tick box format. No views of service users, staff, relatives and professionals involved in the home have been conducted. A copy of the report has not been sent to the CSCI. Windsor Residential Care Home DS0000023628.V305142.R01.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 2 26 2 27 2 28 2 29 2 30 2 STAFFING Standard No Score 31 X 32 1 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 2 LIFESTYLES Standard No Score 11 2 12 3 13 3 14 2 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 3 2 2 X 2 2 X Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 23 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 YA1 Regulation 4 Requirement The statement of purpose requires up dating to include the changes to the Responsible Individual and the address of the CSCI. The Home must fully complete the assessment of service users needs and aspirations to ensure appropriate support is given at all times. 31/01/06 (Will be assessed once home has had an admission) The service user contract needs to include details of what services are provided for the fees paid. All care plans must contain full information regarding the communication needs of each service user. 31/01/06 Timescale for action 31/01/07 2. YA2 12,13,14 31/01/07 3. YA5 5 31/01/07 4 YA6 12 13 15 31/01/07 5. YA6 12 13 15 Care plans must identify all of 31/01/07 the service users needs, include clear instructions on how to meet those needs, all staff must refer to the care plan, especially when writing the daily reports. Care plans must be regularly reviewed and DS0000023628.V305142.R01.S.doc Version 5.2 Page 24 Windsor Residential Care Home 6. 7. YA10 YA10 8. YA14 information from assessments cross-referenced to the care plan. 10,12,17,20 The use of communal records must be stopped. 10,12,17,20 All confidential information to be stored appropriately at all times. Previous timescale: 31/12/05 17 The cost of a week’s annual holiday for the service user must be included in the fees, therefore paid for by the company. 12,13,14, 15,16 17/11/06 17/11/06 30/03/07 9. YA17 Records of all meals provided to 31/01/07 individual service users must be kept. All service users must have regular nutritional assessments completed. The cook must up attend basic food hygiene training. 10. YA17 12,13 A sampling of food temperatures to be taken and recorded. Previous timescale: 31/01/06 31/01/07 11 YA19 12 13 14 15 Health care needs must be met, 31/01/07 16 17 including using appropriate schedule 3 health assessments such as skin integrity. A recognized skin integrity tool must used, that has not be altered in any way, which affects the overall calculations. That the dispensing of medication is in line with guidelines set by the Royal Pharmaceutical Society. Previous timescale: 31/12/05 All adjustments to medication to be supported by 2 staff DS0000023628.V305142.R01.S.doc 12. YA20 12-14 16 17 23 sch 3 30/11/06 13. YA20 12-14 16 17 23 30/11/06 Page 25 Windsor Residential Care Home Version 5.2 sch 3 14. YA20 12-14 16 17 23 sch 3 signatures at all times. Previous timescale: 31/12/05 The home must use a safe & secure means of transporting medication around the home. Prescribed medication must not be shared between service users. The home must not accept and use medication that has administration instructions “use as directed”. The home must check & record the medication fridge temperature daily. 30/11/06 15. 16. YA23 YA24 Internal & external medicines must be stored separately. 12 13 17 20 All staff must have a full 31/01/07 23 sch 3 understanding of Adult Protection procedures. 12 The home must have an annual 30/03/07 13,23 maintenance programme that is fully implemented. The refurbishment of the home must be completed ensuring all rooms are fit for purpose. Repairs and maintenance work must be completed promptly. To produce and implement an improvement plan for the refurbishment of the main kitchen and the skills kitchen. To produce and implement an action plan for the undersized double bedrooms. To provide appropriate screening double bedrooms that ensure privacy & dignity is maintained. 17. YA25 12 13,23 30/11/06 Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 26 18. YA30 12,13,16,23 A long-term course of action must be implemented to resolve the problem with offensive odours. 31/01/07 19. 20. 21. YA32 YA33 YA34 12 13 18 17 sch 4 19 sch 2 The appropriate type of footoperated bins must be used for clinical waste. 50 of care staff must complete 30/09/07 the NVQ level 2 in care Duty rotas must include staffs 30/11/06 name and designation as well as their hours worked. Recruitment procedures must 30/11/06 include an interview record. The home must ensure that staff that require work permit have the correct permit and seek clarification from the Home Office. Staff employed on POVA first checks must have an appointed supervisor and not work alone. Staff must complete mandatory training and specialist subjects relevant to the needs of the service users. Those teaching the courses must be appropriately trained to provide training. 22. YA35 12 13 18 30/03/07 23. 24. YA36 YA39 25. YA42 New staff must be enrolled on the homes induction programme and complete the training. 18 19 All staff must receive 1:1 formal supervision 6 times a year. 10 12 15 24 The quality assurance programme must include the views of the service users, staff, relatives and other relevant parties. 12 13 17 23 The fire safety checks must be sch 3 & 4 conducted regularly and at the DS0000023628.V305142.R01.S.doc 30/03/07 30/03/07 30/11/06 Windsor Residential Care Home Version 5.2 Page 27 appropriate time interval. Staff must complete fire drill/instruction. 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 YA24 Good Practice Recommendations To equip the kitchen the tools needed to enable those cooking to do so safely, for example saucepans. For the cook to attend a training course in nutrition. For an appropriate person not connected to a complaint to be responsible for investigating it. To review staffing levels taking into consideration the needs of the service users. The registered manager needs a system of support and junior managers to share some of the workload with. 2. 3. 4. YA22 YA33 YA28 Windsor Residential Care Home DS0000023628.V305142.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Residential Care Home DS0000023628.V305142.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. 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