Inspection on 21/06/05 for Winterton House

This inspection was carried out on 21st June 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Winterton House 10/09/07

Winterton House 22/03/07

Winterton House 16/05/06

Winterton House 17/11/05

Winterton House 29/11/04

Winterton House 22/06/04

Winterton House 26/11/02

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Winterton House Hale Road Wendover Bucks HP22 6NE Lead Inspector Maureen Richards Unannounced 21 June 2005 10:00 a.m. 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 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. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Winterton House Address Hale Road, Wendover, Bucks, HP22 6NE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01296 622203 The Fremantle Trust Karen Kelly Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29 November 2004 Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 5 Brief Description of the Service: Winterton House is a care home that is registered to provide care and accomadation to forty one older prople. The home is run and managed by The Fremantle Trust. Winterton house is situated on the outskirts of Wendover town and is close to local facilities, amenities and is accessible by public transport. The accommodation is over three floors and the home is set in beautiful grounds, with garden areas and seating at the front and rear of the building which is accessible to service users. There is parking to the front and side of the building. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Winterton House took place over a whole day on the 21st June 2005. The inspection was carried out by two inspectors. The inspection consisted of a tour of the building, discussions with the manager and brief discussions with staff, discussion with service users over lunch and examining records. The progress made towards meeting requirements and recommendations issued as a result of the last inspection was also assessed. It was established that progress has been made in addressing a high number of requirements from the last inspection and some requirements not fully complied with have been repeated at this inspection. All of the key standards were not assessed at this inspection. What the service does well: What has improved since the last inspection? What they could do better: Further work, training and monitoring of senior staff in assessments and the development of service user plans is required to bring all of the service users plans up to an acceptable standard and to ensure that key information is picked up at assessments and included within service user plans. Specific individual risk assessments must be put in place to manage and reduce potential risks, in particular in the management and prevention of falls. Moving and handling risk assessments must be fully completed and kept under review. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 7 Medication practices must improve to safeguard service users. Systems must be put in place to ensure that safe medication practices are maintained in the absence of the manager. The organisation should ensure that all senior staff are developed in their role to be able to take on the required responsibilities and maintain the required standard of care and practice in the absence of the registered manager. The manager must check and ensure that call bells are sited in all required areas of the home and ensure that all call bells are checked to ensure they are in working order. All areas of the home must be kept clean and hygienic and cleaning materials must be kept locked and secure. Staff training records must include names and dates of training to ensure that all staff have up to date mandatory training. All staff must receive regular formal supervision to support them in their role. 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. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The assessment documentation lacks important information and is not fully completed which results in service users needs not being identified and identified needs not being met. EVIDENCE: Service users are assessed by the staff from the home prior to admission. Staff visit a prospective service user in their home and complete the assessment documentation. Care plans are then developed from this assessment. Two completed assessments were seen. One of the assessments had been fully completed, however issues from the assessment were not transferred into the care plan and therefore identified needs were not being addressed and met. The other assessment was incomplete and did not identify the care support required in meeting the identified need. Previous requirements have been made that the manager must ensure that the assessment documentation is fully completed. Further improvements are required to the assessment process to meet this standard. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 9 Some service user plans are not fully completed, lack specific detail on how care needs should be met and on how identified risks should be managed, therefore not providing staff with the information they need to meet service users needs in a safe and consistent way. Medication practices are unsafe and potentially put service users at risk. EVIDENCE: Six service user plans were seen. Two of the service user plans seen had been developed by the manager to be used as a sample for other staff to follow in the development of service user plans. Both of those plans were found to be easily accessible, detailed and specific as to the care required and showed evidence of service user involvement or record to note that the service user was unable to sign the plan. The other four service user plans seen lacked some personal details, information and specific guidelines on how staff support service users to meet their needs. One care plan made reference to the individual having a short term memory and the action was that a community psychiatric nurse was involved. The care plan did not identify how the short-term memory affects the individual or how staff manage the situation. One service user’s plan identified Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 11 that the service user had depression and the action was to administer medication. This service users plan did not identify how the depression affects the individual or how staff support this person on a daily basis. The daily record made no reference to this individual’s mood and behaviour. In one service users plan a district nurse had recorded for staff to monitor the service users bowel movements and to observe the condition of this individuals skin. There was no reference to this in the service users plan. As identified in standard 3 one assessment documentation seen identified the need to monitor weight and to support with food and fluid intake. There was no reference to this in the individuals plan. Service users plans did not include a review date but the majority of plans seen included written evidence of a monthly review. Some care plans included a night time care plan. This was detailed and specific and showed evidence of being reviewed. Previous requirements have been made to improve service users plans. Progress has been made in meeting this requirement but further work is required in developing the service user plans and in monitoring senior staff in their role of assessments and the development of service user plans. Each service user plan included generic risk assessments but did not include individual risk assessments specific to individuals. The home has a history of a high number of falls and the manager is working with the physiotherapist in putting a system in place to address this at the point of assessment of prospective service users. In the meantime service users considered to be at high risk of falls do not have an individual risk assessment on prevention of falls. This must be addressed as a matter of urgency. Each service user plan included a detailed moving and handling assessment. In one service user plan the moving and handling assessment had not been completed but a moving and handling care plan had been developed. Moving and handling assessments are meant to be reviewed monthly. The majority of moving and handling risk assessments seen indicated that they were overdue for review. The manager confirmed that this was as a result of her being on annual leave and that two seniors had not got this training, which they are scheduled to go on. The home has policies and procedures on the administration of medication. These polices were not seen at this inspection. Guidelines on the procedure for administration of medication are displayed on the inside door of the medication cupboards. The medication records seen indicate that staff are writing the medication on the medication administration record on admission of new service users and where interim prescriptions are received. The home has a procedure in place for all handwritten medication administration records to be signed off by the visiting GP at his weekly visit. However the records seen indicated that this had not happened at the previous week’s GP visit. The medication administration records for one service user indicated that staff had written the same medication twice from the information and medication supplied at the time of the admission. This was picked up by staff the following day and the service user’s own GP was contacted who confirmed what the current Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 12 medication regime was. There was no written record available to support this. This service user had been given two doses of the same medication and there was no evidence to support that the GP had been made aware of this and advice sought. The manager confirmed that staff should always contact the service users own GP to clarify the medication regime prior to writing it on the medication administration records. Practice indicates that staff had not done this. The manager must also ensure that medication administration records written by staff are always checked by a second member of staff to reduce the risk of error. Some medication administration records indicated that prescribed essential medication was out of stock and not given for a period of time, in some cases up to 12 days. There was no indication that staff administering medication had reported this and that the seniors had made arrangements for the relevant medication to be ordered. This must be addressed with staff as a matter of urgency. The medication administration records indicated that in some cases medication had not been administered but the reason for not administering was not explained. One medication administration record showed gaps in administering on two occasions and one service user did not have their prescribed eye drops as the code indicated she was asleep. This medication was to be administered at teatime. Glycerol trinitrate spray was included with one service user’s medication. This medication did not have a label on to confirm that it was this individual’s prescribed medication and it was not included on the medication administration records. The manager must establish if this individual is meant to have this medication prescribed and if so this must be indicated on the medication administration record and a new supply with an individual label on be obtained. Another service user was prescribed glyceral trinitrate tablets as required. The instructions on the box indicated that the medication had to be discarded 8 weeks after opening. There was no indication on the box when the medication was opened and therefore it was not established if the 8 weeks had passed. This medication was due to expire in August 2005. Another stock of this medication was in the medication cupboard and was replaced at the time of the inspection. The medication cupboard in the Hale lounge was disorganised and out of date, eye drops were found thrown in the bottom of this cupboard. The manager must ensure that all out of date medication is removed and returned to the pharmacy and for the medication cupboards to be kept tidy and organised. The home has temazepam which is treated as a controlled drug and appropriate systems are in place to manage controlled medication. Staff confirmed that they were assessed prior to administering medication and care staff are undertaking a level 2 certificate in safe handling of medication training. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 The home offers a range of activities ensuring that service users recreational interests and needs are met. EVIDENCE: The home has been successful in appointing a part time activities organiser. She has met with service users individually to establish their interests and hobbies and to develop the activities programme around those interests. The activities coordinator has got a weekly activities programme in place, which includes arts and crafts, word games, food tasting, gardening, gentle exercise and board games. She is continuing to develop the activities on offer to include activities out of the home. She has made contact with organisations to obtain reductions in entrance fees to support this. Service users spoken with confirmed that they felt they had a good choice of activities made available to them although some service users are reluctant to participate. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) EVIDENCE: None of the above standards were assessed at this inspection. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 22 & 26. Areas of the home have been decorated to provide a homely and welcoming environment for service users. The call bell system is not available in all areas of the home and some of the call bells are not working which could potentially put service users at risk. The communal areas of the home are clean and hygienic however a high standard of cleanliness is not being maintained in the group kitchens and may pose a risk to service users. EVIDENCE: The home is accessible to service users. The home has large grounds, which are pleasant and well maintained with flowers and hanging baskets. The home is bright, welcoming and has a homely feel. The corridor in the ramp area has been nicely decorated and bedrooms have been decorated when they have become vacant. Two of the lounges have damp areas on the walls. The manager has identified for those areas and two corridors to be decorated in this financial year. The door frames and doors in most of the building are badly scuffed and marked. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 16 The home has two lifts, a ramp area and handrails in the corridor and in the bathrooms and toilet areas. The toilet seats are raised. The home has one parka bath, three bathrooms with a manual hoist and one bathroom with an overhead hoist. The home has a mobile hoist on each floor. The home has limited storage space and as a result wheelchairs and hoists are stored in corridors and bathrooms. The home has a call bell system in each bedroom and in communal areas. It was noted that there were no call bell in one of the toilets on the first floor. This must be addressed as a matter of urgency. At this inspection one of the call bells in the toilet area did not work and the other illuminated but did not ring and therefore was not answered. The manager must ensure that all call bells are checked and maintained in good working order. Bedrooms and communal areas of the home were found to be clean and odour free. The kitchen area for the Hale lounge was found to have a build up of dirt and grime around the fridge and dishwasher. The fridge in this group had food spillages and was in need of a deep clean. The microwave had food splatters and requires cleaning. The night staff are responsible for the cleaning of the group kitchens and the manager must ensure that this is maintained and monitored at all times. The home has a separate laundry room and machines with sluicing facilities. The home has infection control polices in place which were not requested to be seen at this inspection. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 & 30. Safe staffing levels are being maintained to ensure that service users needs are met. Staff personal files indicate that safe recruitment practices are being maintained to safeguard service users. Some staff training records lacked names and dates and therefore it was difficult to establish if staff are adequately trained to enable them to meet service users needs safely. EVIDENCE: The home has 200 hours of care staff vacancies. The organisation continues to recruit into those vacancies. The rota was seen which indicates that there are six staff plus the senior co ordinator on each daytime shift and one senior plus two carers on the night shift. The vacancies are being covered by relief and agency staff. The manager is not included in the numbers and is therefore able to cover some shifts as the duty person at short notice. The manager has recently appointed an assistant manager, which is a critical post in supporting her to manage the home and supervise and monitor staff. The home has a part time activities co ordinator as outlined under standard 12. The home has a part time 20 hours administrator post vacancy and is getting admin support from other homes within the Fremantle Trust until this post is filled. The home has separate kitchen and domestic staff. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 18 Staff on duty confirmed that the staffing levels are being maintained as outlined above and that the senior was not included in the numbers. The seniors on duty felt this enabled them to carry out their role more effectively and they were able to provide support to all groups during the shift. The home continues to support staff on NVQ 2 care training and at the time of this inspection had one person undertaking NVQ 3 and eight staff pursuing NVQ2. The registered manager has acquired the NVQ 4 and is an NVQ assessor. The NVQ status of agency staff cannot be predicted. Staff recruitment is managed by the home supported by Fremantle head office in line with the Fremantle’s policy and procedures. Four staff files were examined including those of two staff who had recently been appointed. It is noted that the Fremantle reference form does not have space for the date and is not date stamped on receipt in the home or human resources department. The files of recently appointed staff had completed application forms, interview notes, two references, ‘POVA First’ checks prior to taking up post, enhanced CRBs, a photograph of the employee, health fitness reports, a statement of principal terms and conditions of employment, emergency contact details and a photocopy of the person’s birth certificate. The registered manager said that new staff were given a copy of the GSCC codes of conduct. The home does not employ volunteers. The home has a copy of the Fremantle Trust training policy. The Fremantle Trust maintains an ongoing training programme and the home has access to this as required. Training appears to be categorised as induction, foundation and mandatory. According to the training matrix (the summary of training attended) staff in the home have attended courses on the protection of vulnerable adults (POVA), care planning, nutrition, equal opportunities, effective supervision and challenging behaviour. The dates of attendance on the induction programme was not clear for two staff and on the foundation course for three staff. Foundation and mandatory training covers moving & handling, first aid, food hygiene, medication, fire and infection control. Individual files examined included records of attendance on training on POVA, fire awareness, food hygiene, medication, infection control, health & safety, moving & handling and counselling. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 Senior staff practices in the absence of the registered manager potentially compromised the safety of service users. All staff do not currently receive supervision six times a year which would offer them support and enable them to review their practice to ensure that good quality care is being provided. Safe storage of hazardous cleaning materials is not being maintained and potentially puts service users at risk. EVIDENCE: Standard 31 was not fully assessed however there is evidence that the manager has been working to meet requirements from the previous inspection to improve standards. The manager had recently been on leave and there were indicators in the assessment documentation of service users, their plans and Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 20 medication practices that the required standard and agreed practices were not being followed at this time. Weaknesses in supervision (which are known as ‘key sessions’ in the home) identified at earlier inspections are being addressed. Records are retained in individual folders, which may also include the job description, the Fremantle Trust philosophy, Fremantle Trust objectives, and details of induction and training. The structure meets the requirement of standard 36.3 but pressures on staffing appear to be preventing its full implementation for all care staff to the minimum standard of six times a year. Standard 38 was not assessed at this inspection, however during the tour of the environment it was noted that the cupboard under the sink in one of the group kitchens was unlocked. This cupboard contained hazardous cleaning materials, which could cause injury to a service user. This must be addressed as a matter of urgency and systems put in place to ensure that cupboards containing hazardous cleaning materials are kept securely locked. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x 2 x x x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x 2 x x Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 22 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 3 Regulation 14 Timescale for action The manager must ensure that 31ST the assessment documentation is August fully completed ( PREVIOUS 2005 TIMESCALE OF 31/12/04 NOT MET) The manager must ensure that 31st August service user needs identified at 2005 the assessment are incorported into the service users plan. The manager must ensure that 30th care plans provide specific September details on how needs are met 2005 and monitored. Care plans must be dated,signed, show evidence of service user involvement and evidence of review as needs change. ( PREVIOUS TIMESCLE OF 31/01/05 NOT MET) The manager must ensure that 30th all service user plans include up September to date risk assessments specific 2005 to service users. ( PREVIOUS TIMESCALE OF 31/01/05 NOT MET) Specific risk assessments in the mangement and prevention of falls must be put in place for service users identifed as being at risk of falling. The manager must ensure that 30th moving and handling September assessments are fully completed 2005 Version 1.30 Page 23 Requirement 2. 7 15 3. 7 15 4. 7 13 5. 7 13 Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc 6. 7 17 7. 9 13 8. 9 13 9. 9 13 10. 9 13 11. 9 13 12. 9 13 13. 9 13 on admission and are reviewed monthly as indicated on the assessment documentation. ( PREVIOUS TIMESCALE OF 31/01/05 NOT MET) The manager must ensure that the personal details information sheet is fully completed on admission. (PREVIOUS TIMESCALE OF 31/12/04 NOT MET) The manager must ensure that staff establish and consult with the approprite professionals the medication regieme for new service users. The manager must ensure that medication administration records written by staff are always checked by a second member of staff to reduce the risk of error. The manager must ensure that service users prescribed medication is kept stocked and a system must be put in place to ensure that all staff are aware of their responsibility to support this. The manager must ensure that all medication adminstered is signed for and ensure that full explanantions are given as to why medication is not administered. (PREVIOUS TIMESCALE OF 31/12/04 NOT MET) The manager must ensure that all medication prescribed is labelled and included on service users medication adminstration record. The manager must ensure that medication with a shelf life once opened is dated when opened and first used. The manager must ensure that H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc 30th September 2005 31st July 2005 31st July 2005 31st July 2005 31st July 2005 31st July 2005 31st July 2005 31st July Page 24 Winterton House Version 1.30 14. 22 13 15. 22 13 16. 26 23 17. 38 13 18. 19. 30 36 18 18 all medication cupboards are kept tidy and organised and a system put in place to dispose out of date eye drops and medication out of the cupbaords on a regualr basis. The manager must ensure that a call bell is sited in the toilet and check to ensure all areas of the home have call bells within easy reach of service users. The manager must ensure that all call bells are in working order and a system put in place to maintain this. The manager must ensure that a deep clean of all of the group kitchens take place and that an acceptable level of cleanliness is established and maintained at the home.(PREVIOUS TIMESCALE OF 31/01/05 NOT MET) Hazardous cleaning materials must be kept in a locked cupboard. The manager must ensure that safe storage of chemicals is maintained and monitored.(PREVIOUS TIMESCALE OF 30/11/04 NOT MET) Staff training records must be updated to include the date of the training. All staff must receive at least six supervisions a year.(PREVIOUS TIMESCALE OF 31/01/05 NOT MET) 2005 31st July 2005 31st July 2005 31st July 2005 31st July 2005 31st July 2005 31st August 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 25 Winterton House 1. Standard 31 2. 29 The organisation should support the manager in the training and development of the senior staff to take on key responsibilites to support her in her role and to ensure that senior staff are able to provide the same standard and safe practice during her absence. The referance request form should be updated to include the date of the referance or stamp dated on receipt of a referance. Winterton House H53_H02_S23035_Winterton House_UI_V233694_21 06 05_Stage 4MR_js_ces.doc Version 1.30 Page 26 Commission for Social Care Inspection Cambridge House, 8 Bell Business Park, Smeaton Close Aylesbury Bucks, HP19 8JR 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. 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