Inspection on 18/04/07 for Winslow House

This inspection was carried out on 18th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Winslow House 28/03/06

Winslow House 19/09/05

Winslow House 23/02/05

Winslow House 28/09/04

Winslow House 08/01/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Winslow House Springhill Nailsworth Glos GL6 0LS Lead Inspector Sharon Hayward-Wright Key Unannounced Inspection 10:00 18 & 19th April 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 Winslow House DS0000044887.V330190.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. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Winslow House Address Springhill Nailsworth Glos GL6 0LS 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) 01453 832269 01453 836423 winslowhouse@invictawiz.co.uk Winslow House Ltd Mrs Jean Ellen Walker Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th March 2006 Brief Description of the Service: Winslow House is a Victorian property, which has been converted and extended to provide attractive accommodation for elderly residents who require personal care. It is registered to accept up to 35 people. The Home has been equipped with a shaft lift plus a number of disability aids to assist the frail elderly people living there. The communal areas consist of a large lounge/dining room on the first floor with one lounge, a dining room and a large conservatory/dining room on the ground floor. The gardens are attractively laid out and well maintained. Winslow House is situated within walking distance of Nailsworth town centre and has the benefit of attractive views of the surrounding countryside. The fees for this home range from £450 to £850 per week and extras that are not included in the fees include newspapers, chiropody and hairdressing. Both the Statement of Purpose and Service Users Guide are available in the main entrance to the home and this includes a copy of their last inspection report. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector carried out the site visit, which took two days in April 2007. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The Registered Manager and Registered Provider were available during both days of the site visit. A total of 26 standards were inspected. Several people living at the home were spoken with to ascertain their views on the care and services provided. A number of surveys were sent to the home prior to the site visit for people living at the home, staff and visitors to the home. Comments from these surveys have been used in this report. The comments received from people living at the home during the inspection all indicated they are very happy. The Registered Manager and Registered Provider and care staff were spoken with throughout the inspection and were helpful and co-operative. No requirements have been issued at this inspection. What the service does well: The homes Statement of Purpose and Service Users Guide provide people living at the home and proposed people with the information about the services offered. Comments received both during the site visit and on surveys said the home makes all visitors feel welcome. A number of staff have worked at the home for a long time and this results in consistency for the people living at the home. The continued investment in the home ensures people live in a pleasing and pleasant environment that is comfortable and safe. Feedback received from visitors to the home praised the high standard of the environment. The home has exceeded the recommended 50 of care staff trained in NVQ level 2. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 6 Safe recruitment procedures are in place to reduce any risks to people living at the home. The home regularly reviews aspects of its performance through a programme of self-review and consultations, which include seeking the views of people living at the home, their relatives and staff. 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. Winslow House DS0000044887.V330190.R01.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 Winslow House DS0000044887.V330190.R01.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): 1, 3, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes admissions procedures provides prospective people and their families with the information and the opportunity to visit, enabling them to make an informed decision about the home and assurances their needs can be met. EVIDENCE: The home has reviewed both their Statement of Purpose and Service Users Guide following the implementation of the new Care Home Regulations that came in to force in September 2006. Copies of both of these guides are available in the main entrance to the home and all people living at the home have a copy of the Service Users Guide in their room. The home has included in their Statement of Purpose copies of the results of questionnaires they have sent out to people living at the home and relatives. One relative spoken with Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 9 during the inspection said they ‘knew it was the right home when the walked through the door and their relative is very happy here’. Comments received on surveys of people living in the home all said they had received enough information to be able to decide if the home was right for them. Pre admission assessments of two recently admitted people were examined. Both of these people had assessments completed by the Registered Manager and one person who was funded by the Community and Adult Care Directorate also had one completed by a Social Worker. Consideration should be given to the pre admission assessments being dated and signed by the member of staff completing them as evidence they were done prior to the person moving in to the home. One person living at the home said they had completed an application form following communication with the home that they were interested in moving in, then the Registered Manager had visited them in hospital. They were unable to recall if the home had written to them confirming the home could meet their needs but did say they had signed a contract. This person confirmed that their family had visited the home prior to them moving in, as they were not able. A comment received on one survey for people living at the home said they ‘ looked around the home prior to moving in and had a trial period and I am quite contented now and settled in well’. A visitor to the home had written on their survey ‘we were shown around by a nice director who asked mum what she thought’. Intermediate care is not provided by the home. Winslow House DS0000044887.V330190.R01.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): 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. The home has a clear and consistent care planning system in place that could be further improved by adding specific information about individual care needs. The Medication systems used by the home require some minor improvements to ensure that people are not put at any risk of potential errors. People living at the home are treated with respect and their dignity maintained. EVIDENCE: The care of three people who live at the home was examined in detail. This included reading care records, speaking to the person and a member of staff. The home uses a computer based programme for assessments and care plans. All three had an assessment of need that had evidence of frequent reviews. Care plans were in place for any identified care needs, however in places these lacked individual information about each person’s specific needs. The Registered Manager started to address this during the site visit. The home has Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 11 introduced a new form following the Mental Capacity Act, which assesses people’s ability to make choices in their daily lives. A life history is also included with a daily routine and past medical history. A summary of risk assessments is included and this covers moving and handling and falls. Other assessments used are for pressure areas and cognitive ability. One person had a risk assessment for the use of a wheelchair outdoors. Daily records and a weekly summary are also maintained. Copies of care plans are kept in each person’s room and evidence was seen of a relative signing the care plans to agree the care being provided. The results from the surveys sent to people living in the home said that in the vast majority of cases they receive the care and support they need. Evidence was seen of health professional input into peoples care. This included GP’s, Community Nurses, Chiropodist, Physiotherapist and Dentist. One person said they have been able to keep their GP they had at their own home following admission to the home. Surveys completed by people living at the home said they always receive the medical support they require. Medication systems used by the home were examined. Records are maintained of medication received into the home, administered and where necessary returned to the local pharmacy. No people were self-medicating at the time of the site visit, but the Registered Manager said people could do so following an assessment completed by the home. Each person has a front sheet with their photograph and list of allergies if needed. The Registered Manager has also included a list, which details what each medication is for. Medication Administration Records (MAR) were seen and the Registered Manager had noticed several gaps where medication was not signed for. This was in the process of being addressed. Hand written entries should be checked and signed by a second member of staff to reduce any risks to people living in the home. One entry did not have the instructions for use and this could potentially place service people at risk. The home needs to look at ways of recording when prescribed creams are being administered, as at the time of the inspection it appears they are not being given. Consideration should be given to devising care plans for people who have ‘prn’ or as and when medications. Homely remedies list was seen for each person living at the home. Staff receive training prior to administering medications and are then observed by a senior member of staff. The staff use trolleys to transport the medication around the home. Staff signature and initials list is available and a drug reference book, which should be updated as it is dated 2006. The staff check and record the fridge temperature daily and a thermometer is on the wall but the home do not record the temperature. The Registered Manager now takes a photocopy of prescriptions to check against the MAR sheets. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 12 The home has three-monthly audits undertaken by the chemist they use and the Registered Manager said she also audits the medications systems used but does not maintain records of this. People living in the home in relation to privacy and dignity expressed no concerns. Staff were observed knocking on doors prior to entering people’s rooms. A number of people had their own telephones in their rooms. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 13 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. People living at the home have the opportunity to participate in an activities programme and to maintain links with people who are important to them and the local community. People living at the home receive a balanced and varied selection of food. EVIDENCE: The home has an activities coordinator who plans activities and other members of care staff are allocated to undertake these. A poster is on the notice board displaying the planned activities for a month. Another poster was seen advertising planned ‘mystery tours’. Artwork undertaken by people living at the home is displayed. During the two-day site visit a church service was taking place, singing with members of the staff and other games. People spoken with during the site visit were happy with the activities provided and said they could chose whether they take part or not. A visitor was pleased to see that their relative had taken up ‘knitting’ again since moving into the home. The responses received on the surveys filled in by people living in the home said that on the whole they could take part in activities arranged. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 14 Visiting to the home is not restricted and visitors were seen during the inspection. One visitor spoken with said that ‘they are made to feel very welcome when visiting the home’. Visitors were seen being offered beverages. Several people living at the home attend outside clubs. People living at the home confirmed they are able to make choices about their daily lives. These include the times of getting up and going to bed, where to eat their meals and if they want to join in activities. Voting papers for the local elections were seen in the home and where able people can vote. Advocacy information is available in the main entrance to the home. One person confirmed that their family have Power of Attorney so they do not need to worry about financial issues. Lunchtime was observed in the two down stairs communal dining/sitting rooms and they appeared to be a very sociable event with the staff serving the food. People living at the home confirmed that they are able to choose where they have their meals. Copies of the menus for the day are displayed on each table and every morning people in the home are offered a choice of what is planned for that day. One comment received on a survey completed by a person living at the home said ‘98 of the time we receive fruit salad and it is a bit repetitive’. The Registered Manager said that fruit salad is offered at lunchtime as they have their main pudding at teatime and they want to ensure a health diet, however yoghurts are also available if people wish to have them. The home has received a ‘Fit to Eat’ award issued via Environmental Health. Three people require a liquidised diet and on the first day of the site visit all the courses were liquidised together and served in a bowl. This was discussed with the Registered Manager who said that they have tried several ways of presenting the meals but this has proven to be the best way, however on the second day of the site visit one of these people requiring a liquidised diet had all courses liquidised separately and it was presented on a plate. This person was observed to manage to eat the meal independently but they would have benefited from a plate guard. The Registered Manager said they normally use plate guards and would ensure they provide one. The inspector is mindful that they have only met this person during the site visit and have limited knowledge of their care needs. Consideration should be given to documenting in the care records where required the individual needs of each person who has assistance or aids to eat their meals. The Registered Manager started to do this during the site visit. Results of the surveys completed by people living in the home said that in the majority of cases they ‘usually like’ the meals in the home. Feedback received during the site visit was all positive. The cook and Registered Manager confirmed that people in the home contribute to the menus at their meetings. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 15 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. The home has a complaints procedure in place to ensure the view of people living at the home or visiting have their views listened to. Arrangements are in place to protect people living at the home from possible abuse. EVIDENCE: The home has not received any complaints. A copy of their complaints procedure is displayed in the home. Surveys completed by people in the home said that in the vast majority of cases they know who to speak to if they were unhappy and all said they know how to make a complaint. Surveys received from visitors to the home said they know how to make a complaint and three had said ‘yes’ that the home had responded appropriately if they had raised concerns. People living at the home spoken with during the site visit said they knew who to speak to if they had any complaints or concerns. Staff at the home receive training in the protection of vulnerable adults in the form of a video and questionnaire and a copy of the ‘Alerters Guide’. Staff that are undertaking or have completed the NVQ training also complete a unit in relation to abuse. It was discussed with the Registered Manager about staff accessing training provided by the local council to add to what the home Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 16 provides. One member of staff confirmed that they have completed the video and questionnaire as part of their induction programme. Policies and procedures are in place and include abuse; whistle blowing, management of aggression and protection of vulnerable adults. A copy of the ‘No Secrets’ guidance is also available. The Registered Manager said the home is reviewing their challenging behaviour training. No staff have been referred to the POVA list. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The continued investment in the home ensures people live in a pleasing and pleasant environment that is comfortable and safe. EVIDENCE: A tour of the environment took place and several rooms belonging to people who live there were seen. In a number of these rooms the person had their own belongings and furniture, which made them all look individual. The home has continued to invest in the environment with a redecoration programme that has included two of the communal areas downstairs and the upstairs lounge/dining area. New furniture, curtains and carpets have also been provided. The laundry and storage area for linen has been redecorated and new cupboards provided. Following an Environmental Health visit the home Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 18 has changed the ceiling in the kitchen and they have further plans to refurbish this area along with the staff toilet. One visitor to the home commented on how ‘lovely’ the environment is and there are never any odours. Outside a large patio area has been created which two people living at the home were enjoying sitting in the sun. Both people said how nice the patio was and they like to spend their time out there as they can look at the views of the countryside and watch the ‘goings on’ in the local village. The kitchen area was looked at and all the required health and safety checks were in place. A comment on a survey completed by a person living at the home said ‘odd jobs take a while to get done’, this was relayed to the Registered Manager and Provider who said they would look into this. The laundry area was also visited and a discussion with one of the assistants took place. The home has the appropriate washing machines with a sluicing cycle and tumble dryers. The laundry assistant said at times they do soak soiled clothing, consideration must be given to the home not undertaking this practice as it can put the member of staff at risk. The home does have the appropriate linen bags that are put straight into the washing machine. The Registered Manager said they do not encourage this practice and would ensure that it is stopped. Staff were observed wearing protective clothing when needed. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. The home is confident that the numbers and skills of staff ensure the needs of the people living at the home are met. Safe recruitment procedures are in place ensuring that people living at the home are protected. The home provides a training programme for staff to ensure they are trained and competent to do their jobs. EVIDENCE: Duty rotas were discussed with the Registered Manager, who is confident that the needs of the people living at the home are being met. Part of the computer programme used also assess the dependency levels of the people at the home and the Registered Manager uses this to ensure staffing numbers are appropriate. Ancillary staff are also available to assist care staff. Comments received at the site visit and on surveys completed by people living at the home and visitors all praised the staff, saying they are very caring and helpful. One visitor commented that they ‘ look after their relative well’. Staff spoken with and on their surveys said they like working at the home as there is a good team spirit and the home is well run. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 20 A total of twenty eight-care staff work at the home and of these nineteen have completed NVQ 2 and one has NVQ 3 training. Two care staff are currently undertaking the NVQ 3 training. The personnel files of four recently appointed staff were examined. All contained the appropriate checks as required by the Care Home Regulations. The home uses the booklet ‘Skills for Care’ as part of their induction training as this links to NVQ. Mandatory training is also included as part of the induction course as well as abuse training. A recently appointed member of staff confirmed they had completed an induction programme. Certificates were seen as evidence of ongoing training provided by the home. Staff confirmed that they receive training. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 21 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, 32, 33, 35, 36 & 37 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People living in the home can feel confident that a competent management team runs it in an open and supportive way. The home regularly reviews aspects of its performance through a programme of self-review and consultations, which include seeking the views of people living at the home, their relatives and staff. Systems are in place to manage service users monies. As far as is reasonably practicable the health, welfare and safety of people living at the home are promoted and protected. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 22 EVIDENCE: There have been no changes to the management of the home. The Registered Manager has been managing the home for a number of years and has completed the NVQ 4 training. She has also completed the NVQ Assessor’s award and undertakes training with the staff in the home. The Registered Provider is also actively involved in the running of the home. When the Registered Manager or Deputy Manager are on duty they are extra to the numbers of care staff. People living at the home, staff and visitors all said the Registered Manager and Provider are approachable and friendly and they could go to them if they had any concerns. Every year the Registered Manager and Provider complete a full audit of the home and the format used is based on the National Minimum Standards for Older People. The staff undertakes audits of each persons room on a random basis and the results of these are discussed at staff meetings. Questionnaires are sent to people living in the home, relatives and other stakeholders. Copies of some these questionnaires are displayed in the Statement of Purpose. The home has copies of these questionnaires around the home so anyone is able to take them and fill them in. Meetings are held for people living in the home on a three monthly basis and staff meetings also take place. Any accidents involving people living at the home are audited. The Registered Provider has a development plan in place for the home. The home looks after monies and valuables for a number of people living in the home. Records are maintained of furniture and belongings brought into the home by people living there. A secure place is provided for storing people’s monies and valuables and the appropriate records are maintained. The Registered Manager has a plan in place to ensure care staff are supervised at least six times per year. The Registered Provider supervises the other staff in the home. Records were seen of sessions and the Registered Manager said each member of care staff has an annual appraisal. The home needs to add more detail to the food records maintained to ensure for example types of soup are documented along with any alternatives to the menu. The maintenance man maintains records of all checks he undertakes in the home and these include water temperatures, fire equipment and windows to ensure restrictors are working. Servicing of boilers, electrical systems and other equipment was seen. The home has completed their fire risk assessment and has had discussions with the local Fire Service about their evacuation procedure as each person Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 23 living at the home has been assessed for their ability to exit the home if there was a fire. Information about this is provided for the staff. Risk assessments for the home are available and a health and safety poster is also in the home. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 24 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 X 3 3 2 4 Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard OP3 OP9 OP9 OP9 OP9 OP18 OP38 Good Practice Recommendations The home should date and sign all pre admission assessments as evidence they were completed prior to admission. The home should ensure hand written entries are checked and signed by another member of staff to reduce any risks to people living at the home. The home needs to devise away of recording when prescribed creams are administered. The home needs to ensure the directions for each medication are written on the Medication Administration Record. The Registered Manager should record the medication audits she undertakes. The home should consider accessing training for staff in abuse that is provided by the local council. The home needs to add more detail to their food records to include for example, types of soup and any alternatives DS0000044887.V330190.R01.S.doc Version 5.2 Page 26 Winslow House provided that are extra to the menu. Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Winslow House DS0000044887.V330190.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!