Inspection on 22/03/07 for Winterton House

This inspection was carried out on 22nd March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Winterton House 10/09/07

Winterton House 16/05/06

Winterton House 17/11/05

Winterton House 21/06/05

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 Barbara Mulligan Unannounced Inspection 22nd March 2007 10:30 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 Winterton House DS0000023035.V327824.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. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Winterton House Address Hale Road Wendover Bucks HP22 6NE 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) 01296 622203 admin@fremantletrust.org 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 DS0000023035.V327824.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th May 2006 Brief Description of the Service: Winterton House is a care home that is registered to provide care and accommodation to forty-one older people. The home is run and managed by The Fremantle Trust. Winterton house is situated on the outskirts of Wendover town and is reasonably convenient for local amenities and is accessible by public transport. The accommodation is over three floors and the home is set in very pleasant 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. Fees at the time of this inspection range from £397.79 to £550.00 per week. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was undertaken on Thursday 22nd March 2007 at 10:30am. The visit consisted of discussions with the Senior Support Worker who was running the home on the morning of inspection, the Operational Manager for the home, care staff and service users, a tour of the premises and an examination of the homes records, policies and procedures. The inspection officer was Barbara Mulligan. The Senior Support worker is Catriona Liddy who assisted wit the inspection and the Operations Manager is Mark Kingman who was present and assisted with the inspection. . Twenty-five of the National Minimum Standards for Older People were assessed during this visit to the home. Twenty-one of these are fully met, three almost met and one is assessed as not applicable. As a result of the inspection the home has received three requirements. The inspector would like to thank the Senior Support Worker, the Operational Manager, staff team and all service users who for their cooperation and assistance during this visit. Service users and relatives/representatives, both those interviewed and those who responded to the survey expressed a high level of satisfaction with the care received from support staff. The evidence seen and comments received, indicate that this service meets the diverse needs [e.g. religious, racial, cultural, disability] of individuals within the limits of its Statement of Purpose. What the service does well: The home provides a pleasant and comfortable environment in which service users can live. Individuals are encouraged to personalise their own rooms with their own furniture and personal belongings. One service user told the inspector “you have had a wasted visit because the home is just lovely”. The home has developed an activities programme that offers varied and appropriate recreational activities for the service users living in the home. Meals are of a good standard and presented in an appealing way. Comments made from people who use the service include, “ the food is very tasty” and “the food is always lovely” . Medication is generally well managed in the home with relevant procedures in place for the administration of medicines. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 6 There is a motivated and established staff team who respond to service users in a respectful and appropriate manner. Service users spoken to said that the staff were “very helpful and kind” and “ the girls will do anything you ask them”. The care staff are undertaking relevant training and working towards their National Vocational Qualifications. There is an effective complaints procedure with all complaints and concerns being acted upon promptly, within stated time scales. There is a good range of policies and procedures, providing care staff with relevant information about all aspects of care and the home/organisation. There are effective Quality Assurance systems in place, monthly service user meetings. What has improved since the last inspection? What they could do better: The laundry area needs to be redecorated to ensure the walls are readily cleanable and floor finishes impermeable. The home must send to the Commission evidence of all mandatory training undertaken by staff within the previous twelve months and dates for future training. The home must ensure that testing of the fire alarm system is undertaken on a weekly basis. Please contact the provider for advice of actions taken in response to this Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 7 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. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential service users receive a needs assessment undertaken by staff trained to do so, ensuring that the agency can meet the care needs requirements of service users. EVIDENCE: The pathways to admission is either direct contact with the home for someone who is self-funding or through social services care management arrangements via a ‘central resource team’. Either pathway will lead to an assessment of the prospective service user’s needs. It is the responsibility of the registered manager or a senior staff member to carry out the initial assessment of need. Staff will visit a potential service user either in the hospital or in their own home to undertake the initial assessment of needs. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 10 The inspector observed the assessment documentation for four service users, including those most recently admitted to the home. The admission tool covers personal details, medical history, medication, mobility, allergies, pressure area care, nutritional status, personal hygiene needs, continence needs and mental health needs. The admission documentation seen is fully completed, detailed and demonstrates that prospective service users, family members or representatives are included in the assessment process if this is appropriate. The home does not admit service users for intermediate care so this standard was not assessed during the inspection. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 11 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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system adequately provides staff with the information they need to meet the service users needs. However, these would benefit from a more detailed action plan. Healthcare support for service users is good, which means that their health and well-being is promoted and protected. Medication procedures within the home are clear and there is consistent implementation resulting in safe working practices. The manner in which personal care is delivered ensures service users are treated with respect and dignity and that their right to privacy is upheld. EVIDENCE: The care of four residents was case tracked and their care plans were examined. Following the initial assessment a plan of care is developed. Care plans include assessments, a summary care plan, a night care plan, a moving and handling plan, healthcare interventions, and daily reports. There are assessments of daily living activities (e.g. communication, dressing, continence, memory, mobility), moving & handling, tissue viability, nutrition, Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 12 and in some care plans, falls assessment. The overall system is comprehensive. Following the previous inspection a requirement was issued for care plans to provide specific details on how needs are met and monitored. Care plans must be dated, signed, show evidence of service user involvement and evidence of review as needs change. On the whole care plans are much improved and are detailed and informative. However, several entries in care plans are vague and would benefit from further detail. An example of this includes “ staff to supervise and assist the individual in all aspects of personal care encouraging independence at all times” and “ staff to interact with the individual on a daily basis”. These statements require more detail to ensure that all aspects of the health, personal and social care needs of the service users are met and this is strongly recommended. There are risk assessments in place for pressure area care, prevention of falls and nutrition. However, the overall standard of risk assessment documentation is variable. Several were incomplete, not dated or signed by the author. Others were fully completed, detailed and very informative. It is strongly recommended that all risk assessment documentation is reviewed and changes made as necessary. Most service users are registered with a local GP Practice. Service users can register with their own GP if this is practical and agreeable to both parties. All have access to local NHS Services. Tissue viability assessments are in place for each service user. At the time of the inspection there was one individual that required pressure area care and the information contained within the care plan was up to date and in line with her present and changing needs. Pressure relieving equipment is obtained via the district nurse, occupational therapy or is purchased by the home. A domiciliary optical service visits the home on a six monthly basis. Referrals for a hearing test go through the service users G.P. or the home can contact the local hospital directly. The home works closely with the dietician and nutritional risk assessments were observed in care plans. Weight monitoring was observed in the care plans and this is undertaken monthly. Chiropody services visit the home on a six weekly basis and the home pay for this service. Dental services are accessed in the local village and they will visit service users in the home. Following the previous inspection two requirements were made regarding 1) medication with a shelf life once opened is dated when opened and first used and 2) all medication cupboards are kept tidy and organised and a system put in place to dispose of out of date medicines on a regular basis. This was observed to have been complied with. The home is required to conform to Fremantle Trust policy and procedure for the administration of medicines. The supplying chemist provides medication training for the homes staff. There is also in-house training and staff are required to complete an ‘Induction Check List’ prior to administering Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 13 medication. This includes acquiring information, familiarisation with systems, supervised practice and a test of competence that is signed off by a senior care worker. Medicines are prescribed by the GP and are delivered by the supplying chemist (who also collect any surplus medicines to be returned). Medication storage and medication records were checked. Arrangements for the storage of medicines is satisfactory – in a cupboard, trolley and drugs fridge (where required). The home uses controlled drugs, and the controlled drugs register was looked at. This is completed with two signatures, is legible and up to date. All controlled drugs are stored in a metal cupboard, which complies with the Misuse of Drugs Regulations 1973. The aware of the need to retain medication for a period of seven days after a service user has died. The inspector observed evidence of this on the day of inspection. Service users receive care from staff and health care professionals in complete privacy. Staff were observed during the inspection to knock on service users bedroom doors before entering. Preferred terms of address are identified at the initial assessment and the inspector saw evidence of this in care plans. The homes induction programme includes training regarding privacy and dignity. The Statement of Purpose and Service Users Guide include information about maintaining the privacy of service user’s. Service users can have a key to their rooms if they wish to use this facility. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 14 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems in the home ensure that where appropriate service users are supported to exercise choice and control over their lives. Individuals are able to receive visitors at the home and there are no restrictions imposed on visiting unless requested by the service user. Service users are encouraged to bring personal possessions in with them allowing personal space to reflect the character and interests of its occupant. The presentation and standard of food is good and meets the nutritional needs of service users. EVIDENCE: Care plans show routines of daily living and include bathing, rising and retiring times. Religious observance is recorded in care plans and service users interests are recorded in the initial assessment. As part of the admission process, the home ask service users and/or their families to complete a pen picture of their life to give staff information about previous leisure pursuits, hobbies and other interests. On the day of the visit the inspector observed a quiz taking place. This appeared to be enjoyed most service users in Squirrel lounge and staff Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 15 interaction was carried out in a manner that was respectful and appropriate to the service users. Service users spoken to said they do this regularly and that they enjoy various other activities in the home. Examples given to the inspector includes a weekly church service, manicure sessions, crosswords, knitting circle, hairdressing and film shows. On a notice board outside Squirrel lounge are activities advertising outside entertainers to the home. These included a dance session and light chair to foot movements and a singer. Examples of involvement in the home by local community groups and individuals are visits by mobile hairdressers, various visiting entertainers and a monthly church service. Service users are able to receive visitors in the privacy of their own rooms and are able to choose whom they see and do not see. There are no restrictions on visiting, and this is documented in the Service Users Guide. Family and friends are invited to participate in some of the social event organised. Service users and/or their families are encouraged to look after their own financial affairs whenever possible. If this is not practicable a chosen solicitor will be responsible for an individuals financial dealings. An invitation to bring in personal items of furniture and other belongings is included in the service users guide and this was evident during a tour of the premises. When questioned about service users having access to their personal records, the inspector was informed that this could be facilitated if it was requested. Service users are offered three meals a day. On the day of the inspection the chef was in the process of changing the menus from the winter menus to the summer menus. These cover a four weekly rotating system. A choice of main meal is available. The inspector had the opportunity to join observe lunch in Hale lounge. Lunch was relaxed, unrushed and well organised. All meals seen were attractively presented and plentiful. In discussions with service users it was confirmed that meals are always of a high standard and there are sufficient snacks and drinks available throughout the day. The inspector was told that service users can take their meals in their rooms if they wish and this was the choice of several individuals on the day of inspection. The nutritional needs of service users are assessed and there is evidence of regular monitoring in all care plans seen. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place that enable service users, staff and stakeholders to make comments about the quality of the service in a non-judgemental manner. Policies and procedures to protect service users from abuse are in place, which protect service users from abuse and ensures their human rights are protected. EVIDENCE: The home has a complaints procedure. This includes timescales for responding to complaints and includes information regarding contacting the Commission for Social Care Inspection. The home has received four complaints since the previous inspection. These are well recorded and responded to within timescales. A summary of the complaints procedure is included in the Statement of Purpose and Service Users Guide. There have been no complaints reported to the Commission for Social Care Inspection. The inspector looked at an Adult Protection Policy and within this there are guidelines for staff about the responsibilities of the staff, types and signs of abuse and what to do if you suspect abuse. Abuse awareness training commences at induction. However, training records do not clearly demonstrate if care staff and ancillary staff are up to date with Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 17 POVA training. A requirement has been made under Standard 30 regarding the maintenance of records of all training undertaken by the homes staff. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is good, providing service users with an attractive and homely place to live. However, the laundry area urgently needs redecorating to ensure the walls are readily cleanable and the floor finishes impermeable. Standards of cleanliness at the home are good and ensure service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. EVIDENCE: Winterton House is a care home that is registered to provide care and accommodation to forty-one older people. The home is run and managed by The Fremantle Trust. The home is situated on the outskirts of Wendover town and is reasonably convenient for local amenities and is accessible by public transport. The accommodation is over three floors and the home is set in very pleasant grounds, with garden areas and seating at the front and rear of the building Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 19 which is accessible to service users. There is parking to the front and side of the building. The home is divided into four lounge areas, two larger lounges called Squirrel and Hale lounge and two smaller lounges Firs and Herron lounge. The internal decoration of the home is generally in good repair, and there are personal touches around the home such as flowers, plants, books and pictures. Two of the lounges have damp areas on the walls. The door frames and doors in most of the building are badly scuffed and marked. The kitchen is clean, spacious and well looked after. The home has a large garden that is well-maintained and accessible to service users. There are no CCTV cameras in use within the home at the time of the inspection. Lighting in communal areas is domestic in character and sufficient to facilitate reading and other activities. The furnishings observed in communal areas are of good quality and suitable for the range of interests and activities preferred by service users. There are quiet areas around the home where service users can meet visitors in private. There are accessible toilets available for service users throughout the home and several are close to the lounges and dining area. All radiators have low temperature surface covers and are thermostatically controlled. Emergency lighting is provided throughout the home. Hot water control valves are fitted to all hot water outlets accessible to service users. Laundry facilities are sited so that soiled articles, clothing and infected linen are not carried through areas where food is stored, prepared, cooked or eaten and do not intrude on service users. The laundry walls are extremely dusty and paint is peeling from the walls. This area needs to be repainted to ensure the walls are readily cleanable. This will be a requirement of the report. The home has an infection control policy and the inspector observed this. Instructions are in place for the washing of soiled linen. 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. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 20 There is a small hairdressing room and some areas of this room have been replastered because of damp problems. However this room has not been redecorated and this needs to be undertaken. This is strongly recommended. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 21 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing numbers are adequate to ensure that the assessed needs of the service users are met. However a review of staffing levels needs to be undertaken to ensure staffing numbers are sufficient to support service users needs at all times, especially in Hale lounge. There appear to be effective recruitment procedures in place to ensure service users are protected from harm. It is unclear due to poor training records if care staff and ancillary staff are unto date with mandatory and specialist training, making it difficult to assess if staff are competent to do their jobs. EVIDENCE: The home’s staff rota demonstrates that there are a minimum of six carers and one senior carer in the morning and five carers and one senior carer in the afternoon. Staff spoken to expressed concerns that in Hale lounge the staffing has been reduced from two carers to one carer and one senior carer. The senior carer will also be responsible for the running of the home and will inevitably be required to undertake other duties which will take them away from the hands on care required in Hale lounge. Care staff stated that they are often left on their own with twelve service users. This must be reviewed and is strongly recommended. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 22 There are numerous staff vacancies at the home, however the inspector observed evidence that these are actively being recruited for. The vacancies are being covered by relief and agency staff. There are no staff working in the home who are aged under 18 years of age and there are no members of staff under the age of 21yrs left in charge of the home. The home continues to support staff on NVQ 2 care training and at the time of this inspection thirteen staff had obtained NVQ level 2 training or above and a further twelve staff were working towards NVQ training. The home has so far achieved 34.2 of care staff with NVQ training. Staff records were not accessible on the day of the inspection. The registered manager had the only key to these records and was unavailable during this inspection. Following the previous inspection Standard 29 was assessed as satisfactory. Discussions with care staff confirmed that the recruitment procedure has been followed. There is an induction programme that staff are required to complete within their probationary period. Mandatory training forms part of this induction. Training records are not well organised and it was difficult to assess if staff are up to date with their mandatory training. This includes POVA training, fire training, manual handling, basic food hygiene, first aid and infection control. It is a requirement of the report that evidence is sent to the Commission of staff training undertaken within the previous twelve months and dates for future training. All staff receive a minimum of three paid days training per year. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is no manager in post at present, however a manager has been recruited and will commence in post mid April. The home operates a consistent approach to quality assurance resulting in the home being proactive in identifying issues that may affect the well being of services users. Protocols and systems are in place to ensure service users financial interests are safeguarded. Overall health and safety procedures are in place, however fire testing must be carried out weekly. EVIDENCE: Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 24 The previous Registered Manager has left her post the previous day to take up a new position, at another home, within the same organisation. The Operational manager said that a new manager has been appointed for Winterton House and is expected to commence in post mid April. In the interim period the present assistant manager will act up as manger with support from the Operational manager. The home operates regular monthly staff meetings for all staff. There is an equal opportunities policy in place and this was looked at during the inspection. There are clear lines of accountability within the home and a clear staff structure. The Operational manager informed the inspector that a Quality Assurance audit was carried out between July 2006 and August 2006. This includes sending out service users satisfaction questionnaires to the people living at the home and relatives and/or their representatives. Regular service user meetings take place monthly. Consultation meetings occur annually. Relatives are invited to these meetings. Accident and pressure sores and complaints are monitored on a regular basis. . There is a folder containing compliments and thank you letters, mainly from the relatives of service users. The proprietor regularly sends Regulation 26 visit reports to the Commission. The manager does not undertake the role of appointee for any service users. She said that most families look after their relative’s money and only a small number of individuals require the home to look after personal money. Relatives will bring in small amounts of personal money and written records are maintained of all transactions. Secure facilities are available for the safekeeping of valuables if required. Records were seen for fire safety. These cover the homes fire procedures, practice fire drills, fire prevention, fire alarm testing and emergency lighting testing. Testing of the homes fire alarm systems is not being undertaken on a weekly basis and this must be addressed. This will be a requirement of the report. Evidence of mandatory health and safety training is unclear due to poor organisation of training records. A requirement has been made under Standard 30 regarding training records. Service reports are in place for the maintenance of the stair lift dated August 2006, Gas boiler 12/12/06, Pat testing October 2006, and electrical installation 15/05/2006. There are systems in place for water chlorination and kitchen hygiene. COSHH sheets are up to date and accurate. The inspector looked at Infection Control guidelines that are available for all staff. The homes incident and accident book is completed legibly. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP26 Regulation 23 Requirement Timescale for action 30/07/07 2 OP30 18 3 OP38 23 The registered provider is required to ensure that the laundry area is redecorated to ensure the walls are readily cleanable and floor finishes impermeable. The registered provider is 30/05/07 required to supply to the Commission evidence of all mandatory training undertaken by staff within the previous twelve months and dates for future training. The registered provider is 30/03/07 required to ensure that testing of the fire alarm system is undertaken on a weekly basis. 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 OP7 Good Practice Recommendations It is strongly recommended that all care plans contain DS0000023035.V327824.R01.S.doc Version 5.2 Page 27 Winterton House 2 3 4 OP7 OP19 OP27 detailed action plans to ensure that all aspects of the health, personal and social care needs of the service users are met. It is strongly recommended that all risk assessment documentation is reviewed and changes made as necessary. It is strongly recommended that the hairdressing room is redecorated. It is strongly recommended that a review of staffing levels is undertaken to ensure staffing numbers are sufficient to support service users needs at all times, especially in Hale lounge. Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Winterton House DS0000023035.V327824.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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