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Inspection on 12/11/07 for Winthorpe Hall Care Home

Also see our care home review for Winthorpe Hall Care Home for more information

This inspection was carried out on 12th November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The care plans are kept on computer, which ensures that they are reviewed every month. Those residents seen commented that `the food is quite good,` the carers are very helpful and kind and are sensitive to my needs`, `there are enough carers to see to my needs`. Another resident stated that she had just returned from lunch at a local pub and that she has been out on trips, she also commented that her family visits and are made welcome. A visitor stated that this home is head and shoulders above others that he has seen and this has been confirmed over the last two years when visiting.

What has improved since the last inspection?

The home has an ongoing programme of re-decoration and improvements, as shown whilst looking round the building. The recruitment procedures of the home, including checks from police and adult protection sources, now safeguard the residents. Six staff are currently studying courses including NVQ`s (National Vocational Qualifications), protecting vulnerable adults, first aid, moving and handling and fire training.

What the care home could do better:

The provider must produce an up to date statement of purpose, which complies with The Care Homes Regulations. All residents must be given a copy of the service user guide in a form that is user friendly and summarises the homes main service user guide. The provider should consider using locked cabinets in bathing and toileting areas for disposable gloves and aprons for carers to have easy access. The provider must send a letter to prospective residents advising them that the need of the residents can be met or not by the provider. Those residents who are at risk of falls must have a risk assessment detailing the level of risk and action required to prevent falls. The provider must provide adequate heating to the home for the comfort of residents at all times of the day and night. The provider must undertake surveys of residents and visitors views relating to the running of the home and those services supplied.

CARE HOMES FOR OLDER PEOPLE Winthorpe Hall Care Home Gainsborough Road Winthorpe Newark Nottinghamshire NG24 2NR Lead Inspector Doug Tunmore Unannounced Inspection 12th November 2007 10:00 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 Winthorpe Hall Care Home DS0000024670.V354136.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. Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Winthorpe Hall Care Home Address Gainsborough Road Winthorpe Newark Nottinghamshire NG24 2NR 01636 701826 01636 701234 padron@ntlworld.com 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) Mr R C Pountney Francesca Zerbinati Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may prvide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old Age, not falling into any other category - Code OP The maximum number of service users who can be accommodated is 28. 12th January 2007 2. Date of last inspection Brief Description of the Service: Winthorpe Hall is a privately-owned care home registered to provide accommodation and personal care for up to twenty-eight people over the age of 65 years. It is a spacious, converted manor house, providing accommodation on three floors, with a two-floor extension in keeping with the architecture of the original building. It is situated in the village of Winthorpe, north of the market town of Newark, close to major road networks. A local bus service goes to both Newark and Gainsborough. Amenities available within the village itself include a post office cum general shop, parish church, village hall and public house. The village of Collingham, three miles away, has a larger number of amenities, including shops, a doctor’s surgery, dentist, optician, pharmacy and public library as well as restaurants and pubs. The accommodation contains 26 spacious single bedrooms, 16 of which are ensuite, and one double bedroom. There is a passenger lift to the upper floors. The main lounge areas and dining room are on the middle floor with further sitting areas on the ground floor. The property is surrounded by extensive, well-kept gardens, which provide residents with a tranquil, safe area to walk and sit in. There is a large car parking area for staff and visitors. The fees at the inspection visit on the 12/11/2007 ranged from £350:00 to £420:00 each week. Extras are for hairdressing which range from £5:50 upwards, chiropody £11:00, personal newspapers and magazines. The provider also makes a charge of £7:00 per hour for escorting residents to hospital. Information about the home can be obtained from the manager of the home. Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 5 The service user’s guide is available from the manager and is kept in the office. Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took into account any previous information held by the Commission for Social Care Inspection (commission) including the homes previous inspection reports, their service history and the homes Annual Quality Assurance Assessment form, hereafter in this report referred to as AQAA. Have Your Say surveys were sent to the home by the commission and residents returned six. The site inspection consisted of case tracking a sample of three residents records and assessing their care. The inspector spoke with two of the people who were being case tracked and joined two other people for lunch. The inspector also spent time with the provider/manager and two carers. A partial tour of the home and a review of a sample of the records were also included. What the service does well: What has improved since the last inspection? The home has an ongoing programme of re-decoration and improvements, as shown whilst looking round the building. The recruitment procedures of the home, including checks from police and adult protection sources, now safeguard the residents. Six staff are currently studying courses including NVQ’s (National Vocational Qualifications), protecting vulnerable adults, first aid, moving and handling and fire training. Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 7 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. Winthorpe Hall Care Home DS0000024670.V354136.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 Winthorpe Hall Care Home DS0000024670.V354136.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): Standards 1, 2, 3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do not receive information about the home, which helps them to make an informed decision about where to live. Residents are not informed that the home can meet their needs. EVIDENCE: A previous visit found that the statement of purpose was a one-page document within the service users guide and did not contain all the information required by the Care Homes Regulations, Care Standards Act 2000. This visit found that this document needs further work to meet the above regulations. The inspector gave the provider a list of information which must be included in this document. Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 10 The service users guide is a large, comprehensive document that is kept in the manager’s office. People living in the home are not given a user-friendly summary of this document for their information. In a previous visit dated 12/01/07,it was noted that that one resident stated that, “we looked at the home and liked the look of it but we weren’t given any written information about the home before I moved in”. We looked at two of the files of residents who were being case tracked and found that their was no evidence that they had been written to by the provider confirming that their needs could be met. The registered manager was unaware of this regulation. The providers AQAA states that; ‘We ensure that service users are aware of our web page, winthorpehall.co.uk and can view our Statement of Purpose and our Service Users Guide. Each resident has a written contract. We have in place pre-admission assessments using recognised assessment tools to aid this process’. We looked at two pre-admission assessments and found that the manager uses the assessment tool that Social Services also does for the residents. One resident stated that she was shown around when she first came in and that her son had a look at the home prior to her admission. A visitor confirmed that an assessment of need had been carried out and that he had visited the home which ‘was head and shoulders better’ than others he had seen. Surveys received from residents showed that four had received a contact and six felt that they received enough information prior to admission. The provider does not undertake intermediate care. Winthorpe Hall Care Home DS0000024670.V354136.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): Standards 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans do not address the individual intimate care needs of residents and their wishes regarding their privacy and dignity. Risk assessments are not available to safeguard all residents who have had falls. EVIDENCE: Previous visits have found that care plans are kept as electronic records and are printed for residents and their representatives to be involved in whenever they wish. We looked at one care plan, which was up to date and showed the care needs and reviews undertaken on that resident. However, there was no mention of that residents wishes concerning her privacy and dignity and how these should be maintained for her as an individual. Residents stated that they were involved in their care plans and one said that she had signed her care plan. A visitor also stated that he was aware of his relatives care plan and had been involved in it. Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 12 Disposable gloves and aprons are kept in the carers office on the ground floor. It is suggested that lockable facilities (or other means) are made available in bathrooms and toilets so as to ensure good infection control throughout the home. At a previous visit there was evidence that ‘several healthcare professionals were seen and spoke of co-operation and good liaison between the manager and staff of the home and the district nurses, GPs and other professionals to maintain the health and welfare of the residents’. One resident stated that she has an appointment to see a specialist at the hospital on the 13/11/07. The providers AQAA states that; ‘We have a computerised care planning tool and each service users care plan is updated monthly. All service users have access to doctors, district nurses, opticians, chiropody and community health services as required. Policies and procedures are available and in place for self-medicating service users. Recent inspection from our pharmacist indicated that we are performing an above satisfactory service. All service uses have their own bedroom and can have privacy as and when required’. We looked at accident forms and one resident had three falls on the 26/07/07, 08/09/07 and the 09/11/07. There was no evidence of bruising or injury but there was also no evidence that a risk assessment had been implemented detailing the level of risk and action required to prevent further falls. A previous visit found that ‘when residents present challenging behaviour, not all staff know how to handle the resident to retain their respect and dignity’. This visit found that there had been no training given regarding the above. However, the manager stated that she would look at arranging dementia training for carers. Surveys received from residents showed that five felt that they received the care and support that they needed always and one felt he usually does. Winthorpe Hall Care Home DS0000024670.V354136.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): Standards 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. Daily activities are recorded to show that residents are kept occupied and their wishes catered for. The manager and staff make relatives and friends of residents welcome in this home. EVIDENCE: We looked at the providers activities book and found that a range of activities are undertaken. These ranged from outings to Skegness, museum visit, autumn fare and Whisby garden centre. On the day of this visit a number of residents went to the local pub for a fish and chip lunch. In house activities are also available and residents seen said that they sometimes do activities and another confirmed that she had been out for lunch and other outings. She also stated that her family are made welcome when they visit. Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 14 The providers AQAA states what they do well; ‘We are able to provide a varied and flexible routine for our service users. they are able to make choices with regard to their meals, activities, visits etc. We provide regular resident forums, entertainment and monthly lunch club outings’. A residents forum meeting dated the 03/11/07 showed that residents are engaged in which activities they would like and what activities they wish for in the run up to Christmas. A visitor stated that he visits regularly and is on first name terms with all carers. He further commented that staff have ‘been brilliant, odd ones cannot get on with but overall outstanding’. Those residents who were being case tracked confirmed that there were enough carers to see to their needs with one stating that ‘if I press my buzzer at night they (the staff) come quickly enough’. Surveys from residents evidenced that one felt that activities are always available; three felt they usually were and two stated that they are sometimes available. The manager said that there is always a full choice of menu. The menus were seen and showed that there were choices at lunch. Two residents stated that the food is quite good, with one commenting that she does not often get fruit. Another residents said it was like a restaurant and I had bananas for breakfast. The inspector joined residents for lunch and found that his quiche was burnt on the edges and a resident stated that hers was as well. The provider does not undertake surveys with residents relating to the quality of the food available and how meals are on any given day. Surveys showed that three residents always liked the meals and three usually did. Winthorpe Hall Care Home DS0000024670.V354136.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): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear policies and a responsive and knowledgeable staff team protect residents. EVIDENCE: One complaint had been made since the last inspection and this was fully documented in the homes complaint book. The providers AQAA shows that; ‘We have a complaints procedure that works well and all service users and families are well aware of how to use it. We have had most of our staff undertake an adult abuse course to make them aware of all types of abuse’. Evidence was seen in the form of certificates and talking to carers that they have undertaken adult protection training. Both carers stated that they were aware of what they would do if an issues relating to the harm of residents came to their attention. Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 16 Two residents who were being case tracked stated that they had no complaints at all and ‘we feel safe here and we are all friends together’. A visitor said he has not made a complaint and has no concerns. Five residents surveys showed that they knew who to speak to if they were unhappy and one usually did. Winthorpe Hall Care Home DS0000024670.V354136.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): Standard 19, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well decorated and maintained in a clean, tidy and hygienic state. The home was not comfortable due to lack of heating to keep residents warm. EVIDENCE: Previous inspections have found that the home has an ongoing programme of re-decoration and renovation to make it a comfortable, homely and pleasant place for the residents in which to live. During this visit to the home, everywhere looked clean and tidy and residents confirmed this is always so. Residents have confirmed in previous visits that their rooms are spacious, pleasantly decorated and have lovely outlooks. This was confirmed on the tour of parts of the building. Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 18 All entrances to the home are accessible to wheelchair users. Equipment for specialist use has been provided where necessary for people with physical disabilities. Three surveys showed that the home is always clean and tidy and three indicated that the home is usually clean and tidy. The providers AQAA confirms that; ‘This year we have re-furbished seven bedrooms and two lounges. In addition we have installed secondary glazing on 13 bedrooms (listed building) and three new high efficiency boilers’. The original part of the building is Grade One listed in which alterations are not permissible to the ‘fabric’ or ‘design’ of the building. The manager says that the high ceilings and single frame, original windows in this area of the home can cause draughts and cold areas. Some rooms are shut off when not in use to keep the rest of the building warm. On a previous visited dated 12/01/07 a relative had concerns that the residents are often not warm enough. Several residents confirmed this, although others said they are warm most of the time. Also at that visit carers commented on the lack of adequate heating. This inspection started at 09:40 and finished at 15: 40 hrs. During this time a number of rooms were visited including the dining room where lunch was taken, the blue room where a resident was seen by the inspector, one bedroom and two lounges. All these rooms were cold throughout the day. Radiators in these rooms were examined and found not to be working or not very warm. One resident said ‘I would like my bedroom to be warmer’. Another confirmed that it was cold in the home sometimes. A number of residents in the lounge also said that they were cold. The manager said that she would install gas heaters in the dining room. Before leaving the home the provider had managed to bleed radiators and circulate heat to the above rooms. The provider does not undertake surveys so as to gain residents views as to whether they are cold or not in the winter. A relative commented that sometimes its a little bit more chilly than others. Winthorpe Hall Care Home DS0000024670.V354136.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): Standards 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. Residents benefit from a knowledgeable staff team, and they are protected by robust recruitment and training processes. EVIDENCE: A previous visit evidenced that numbers of staff on duty at any time meets the needs of the residents. Those residents seen during this inspection confirmed that there are enough staff to met their needs. The providers rota showed that on the day of this visit adequate staff were on duty. Resident’s surveys showed that six felt that staff listen and act on what they say. Four felt that staffs are always available when they need them and two felt they usually were. Previous visits have also found that recruitment procedures are in order, with two references, a police and a protection of vulnerable adults check being obtained as required, prior to employing new staff. During this visit one carers personnel file was seen which showed that checks had been carried as required. Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 20 The providers AQAA sates; ‘We ensure that CRB (Criminal Record bureau Checks), references and a thorough interview takes places before staff are hired. Ensuring that all staff have the opportunity to study for an NVQ (National Vocational Qualification). We have a training matrix and several staff are studying for NVQ2 and two for NVQ 3’. Two carers seen stated that they had undertaken their induction training, which included fire training. They complete induction booklets, which they sign when they feel competent. Staff stated at previous visits that the provider and manager are enthusiastic about them doing plenty of training. One of the two carers seen confirmed that she had adult protection training, basic drugs training, and moving and handling. A second carer said that she has worked there for five months and has only undertaken her induction training. They confirmed that they had not undertaken dementia training or a challenging behaviour course. The manager stated that she would arrange dementia training in the near future. Winthorpe Hall Care Home DS0000024670.V354136.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): Standards 31,33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Records show that residents’ health and general welfare and safety are promoted. Surveys of residents or visitors views are not undertaken which would inform the provider of any issues regarding the running of the home. EVIDENCE: The manager is seen as supportive and encouraging. The providers AQAA provides evidence that; ‘We now have an official registered manager’. Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 22 The manager is currently undertaking the Registered Manager’s Award. Previous visit showed that the provider attends the home regularly each week; he does not complete monthly audit reports on the home but says he monitors the service himself. However, this visit found that regular audits of residents or visitors views on the running of this home are not undertaken so as to gain peoples views that use this service. The manager undertakes regular residents’ forums every six weeks or so. The last forum was held on the 03/11/07 and the minutes showed that an outing for a pub meal was discussed and residents asked for more quizzes in the afternoon and that the hairdresser was rushing them still. The providers AQAA provides evidence that; the proprietor has one full day at the home per weekday to co-ordinate with the manager and staff. We now have a maintenance log. We have upgraded our filing system to clearly show our maintenance contracts, our energy supply contracts. Our new filing system and the procedure for safeguarding the service users pocket money is of a high standard and all monies are receipted and carefully filed’. The providers AQAA also evidenced that maintenance and service histories of all aids and adaptations are carried out as required by law. Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 x x x x x 2 3 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 2 x 3 x x 3 Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4(2) 5(2) Requirement The registered person must ensure that the statement of purpose complies with the Care Homes Regulations, Care Standards Act 2000 and that a copy is supplied to the commission. (Timescale of 14/02/07 has not been met) with a new timescale been set. A system must be established to ensure that all residents have a copy of the providers service users guide so that they can refer to it for information when they so wish without asking the provider for the office copy. A system must be established to ensure that all prospective residents, who have been assessed by the provider and offered a place must be written to by the provider confirming that their needs can be met. A system must be established to ensure that care plans of those residents who have had falls have a risk assessment available DS0000024670.V354136.R01.S.doc Timescale for action 14/02/08 2. OP1 5 14/02/08 3. OP4 14(1) (d) 14/02/08 4. OP7 13(4) 14/02/08 Winthorpe Hall Care Home Version 5.2 Page 25 for the information of carers and which details the level of risk and action required to prevent further falls. 5. OP10 12(4)(a) A system must be established to ensure that residents are treated with respect and dignity, and given privacy at all times. This is partially met but care plans do not show what individual residents requirements are relating to their privacy and dignity. (Timescale of 28/02/07 has not been fully met) with a new timescale been set. A system must be established to ensure that all staff are adequately trained to keep the residents safe from risk of harm or abuse at all times. This is partially met the manager is to arranged for further training regarding dementia and challenging behaviour. (Timescale of 30/04/07 has not been fully met) with a new timescale been set. T A system must be established to ensure that both private and communal areas of the home are kept warm enough to meet the residents’ needs at all times. At this visit parts of the home were found to be cold and residents and carers remarked how cold it was. The provider fixed the heating by the end of the visit. (Timescale of 28/02/07 has not been met) with a new timescale been set. The manager is responsible for ensuring adequate heating to the home for the comfort of residents at all DS0000024670.V354136.R01.S.doc 14/02/08 6. OP18 13(6) 14/03/08 7. OP25 23(2)(p) 28/02/08 Winthorpe Hall Care Home Version 5.2 Page 26 times of the day and night. 8. OP33 24(1) A system must be established to ensure that the opinions, wishes and preferences of the residents is known and given priority to within the home at all times. (Timescale of 30/04/07 has not been met) with a new timescale been set. The manager must ensure that an effective quality monitoring system is in place based on seeking the views of residents so as to measure the success of the home in meeting their needs. 28/02/08 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 Standard Good Practice Recommendations Winthorpe Hall Care Home DS0000024670.V354136.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Winthorpe Hall Care Home DS0000024670.V354136.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!