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Inspection on 21/07/07 for Winthorpe Residential Home

Also see our care home review for Winthorpe Residential Home for more information

This inspection was carried out on 21st July 2007.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

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 service continues to focus on residents individual needs, e.g. residents spoken with said they thought staff were friendly, the food was good and they liked their bedrooms. New Care Plans are comprehensive and detailed to assist staff to deliver care that fits individual residents care needs. A choice of foods is always available to residents. Residents are asked where they want to go on holiday which they said they enjoyed. Staff were found to be friendly and helpful in their dealings with residents. Bedrooms are organised to residents styles of living with personal possessions in them. Facilities are kept in a generally clean and tidy condition. There are residents meetings to ask residents what they think of the home`s services and ask their views about them.

What has improved since the last inspection?

Residents do not carry out any care tasks, the food supplied has been reviewed to introduce more healthier options, that the Protection of Vulnerable Adults check is taken up with staff before they work in the home, to make sure residents are protected from adverse Health and Safety issues, e.g. protection from burning by following up the Risk Assessments for all radiators. The quality of the furniture has been reviewed and is being replaced as needed. More staff training on residents care needs has been provided.

What the care home could do better:

CARE HOME ADULTS 18-65 Winthorpe Residential Home 84 Westcotes Drive Leicester LE3 0QS Lead Inspector Keith Charlton Unannounced Inspection 21st July 2008 1:40 Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Winthorpe Residential Home Address 84 Westcotes Drive Leicester LE3 0QS 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) 0116 233 2107 0116 2339170 winthorperch@aol.com Mrs Patricia Smith Mrs Patricia Smith Care Home 17 Category(ies) of Learning disability (17) registration, with number of places Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home is able to admit the person of category LD(E) named in variation application number V10279 1st August 2007 Date of last inspection Brief Description of the Service: Winthorpe Residential Home is registered to provide care to up to seventeen adults with learning disabilities. The home is a three-story Victorian house situated close to the centre of Leicester. Residents are accommodated in one single and eight shared rooms. In addition to their rooms, residents have access to two lounge / dining rooms and a kitchen. There is a garden to the side of the property. Fees typically range from £344 to £682 per week - this information was provided on the day after the inspection. There are costs for extras hairdressing, toiletries, holidays, transport etc. The Deputy Manager has stated that residents and representatives can be provided with the home’s Statement of Purpose, describing the home’s services, and reference to the last Inspection Report, upon request. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. There are only a small number of residents that can communicate their views so the inspector spent time observing what residents did and their relationships with staff. This was an unannounced Inspection. The Registered Manager and Deputy Manager were on duty to assist with the inspection. Planning for the Inspection included looking at the last Inspection Report, the Annual Quality Assurance Assessment that the Management provided which gives information as to the services that are provided, and assessing any notifications of significant events sent to the Commission for Social Care Inspection by the home. There have been no complaints received regarding the home in the past year. The Inspection lasted seven and a half hours and included a selected tour of the building, inspection of records and direct and indirect observation of care practices. The Inspector spoke with six residents, two members of staff, the Registered Manager and Deputy Manager. What the service does well: The service continues to focus on residents individual needs, e.g. residents spoken with said they thought staff were friendly, the food was good and they liked their bedrooms. New Care Plans are comprehensive and detailed to assist staff to deliver care that fits individual residents care needs. A choice of foods is always available to residents. Residents are asked where they want to go on holiday which they said they enjoyed. Staff were found to be friendly and helpful in their dealings with residents. Bedrooms are organised to residents styles of living with personal possessions in them. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 6 Facilities are kept in a generally clean and tidy condition. There are residents meetings to ask residents what they think of the home’s services and ask their views about them. What has improved since the last inspection? What they could do better: To ensure there is more comprehensive meeting and protection of residents needs a number of features need to be put into place – Specifying what jobs residents do in the home and their agreement to do them, ensuring Care Plans are fully up to date, providing an Activities Programme to provide residents with stimulating activities, ensuring that all staff on duty are fresh by reducing the working week for management staff as long hours are worked which could cause fatigue and impaired work performance, to ensure proper recruitment procedures are in place to protect residents from unsuitable staff, to make sure residents are protected from any adverse Health and Safety issues, e.g. ensuring all fire safety issues are in place, and protection from scalding hot water temperatures. Furniture needs to be erected to replace old worn furniture. The Quality Assurance system needs to include residents views and that of other interested parties to ensure all services are of the highest order. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 7 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 Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An assessment system to meet residents needs will be in place when the need arises. EVIDENCE: All residents have been living in the home for a considerable time. There are Social Service Department assessments on file for current residents, which cover their stated needs. No resident has been admitted without this assessment. The Deputy Manager has stated in the past she will be converting all word documents for residents to a format they understand by the use of photos. Where this is not possible, writing with symbols is recommended. It is recommended that management refer to National Minimum Standard 2 when an assessment is needed for a prospective resident to ensure it contains full details of residents needs so staff can meet them. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 10 The Annual Quality Assurance Assessment states that prospective residents are invited to spend time in the home and have overnight stays if they wish - so they can get used to the home and give them an idea as to whether they wish to live there. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual needs and choices of people living in the home are largely met. EVIDENCE: Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 12 Residents briefly spoken with thought they were well looked after by staff. ‘’Staff are good to us’’. ‘’I don’t have any problems here. I get what I need’’. The inspector case tracked three care records, which largely demonstrated that residents changing needs are being monitored and supported, e.g. one resident had hip protectors provided due to risk of injury from falls. One Care Plan was not up to date regarding medical checks, communication needs and details of current medical problems. Residents said that they make decisions about their lives and have independent life styles as much as possible, e.g. some residents are able to go out on their own and a number of people can use the kitchen - a number of residents were seen to use the kitchen with staff supervision, choosing what clothes they want to wear, what food they want, they clean their own bedrooms, and residents said they could go to bed when they wanted. They are asked their views on important issues in their meetings and these are recorded regarding food, though it is recommended that other relevant issues are also discussed - activities, facilities, outings etc. Individual plans contained details of the circumstances in which residents rights to make particular decisions may have to be limited, e.g. the need to accompany on trips outside because of the lack of road skills and Risk Assessments are in place to indicate what care the staff need to follow. Staff said she had not read all Care Plans yet – the Deputy Manager said she would follow this up. Care records were sparse in detail as to residents lives and some had not been completed for over two weeks. The Deputy Manager said she had noticed this and was taking it up with staff. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents do not always have the opportunity to have a fulfilling lifestyle. EVIDENCE: Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 14 ‘Residents can do what they like but I think that more activities would be nice for less able people’. There was some evidence of activities – one resident likes to sketch, another had an office set up in his bedroom with a desk and typewriter. However it appeared that unless residents actively chose what they wanted to do the other residents were left to watch the TV or chat to each other and the staff. There were some comments that more activities could be provided – e.g. outings, board games, music, singing, entertainers, cooking, cinema, pub trips, swimming, crafts etc. The Deputy Manager said this had been tried in the past but residents were not interested but agreed to take this up again. There was a copy of a residents review on file that asked management to ensure that fuller activities are provided for a resident. Residents talked about going on holiday this year, which they were looking forward to. The Deputy Manager said she was trying to organise this at the moment. Residents were seen going out to activities – e.g. Gateway Club where there was a disco and indoor games, going out to voluntary/ paid work for two residents and one resident said he always saw his mother. Another resident goes into town on his own. Staff said residents go to colleges, local pubs, local shops etc. The Annual Quality Assurance Assessment stated that there are to be more day trips. It is recommended that residents be shown leaflets for places they may like to visit. There was evidence on file that residents religious needs are respected as to anyone wanting to go to church. Staff said residents could have their visitors to the home and there were no restrictions on visiting times. Food records showed that residents were given a choice of food for each meal. Records need to include what vegetables are served so variety can be seen to be offered to residents. For the dinner observed there were two fresh/frozen vegetables and there were two courses, though no dessert. It is recommended that a dessert be provided, e.g. fruit, yogurt etc. The Deputy Manager said she had tried to encourage healthier meals but residents did not want them. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 15 The meal tasted was of a good flavour and included vegetables. Residents were seen to queue to get their meal from the kitchen – this appeared institutional. It is recommended that residents are served from the table, with residents who are capable to help themselves from serving dishes for vegetables. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive generally good personal support with their physical and emotional health needs being met in most circumstances. EVIDENCE: Files contain details of medical appointments and check ups on an individual basis - from nurses, GPs, dentist, chiropodist, etc. Through observation, discussion and records, it was demonstrated that clients receive support in the way they prefer and require it. Care Plans indicate that health care needs are covered – e.g. personal care, communication, social skills, work and play etc. Accident Records showed few falls and all injuries had been followed up appropriately. The Deputy Manager said if there was evidence of potentially serious injuries, e.g. head injury, then staff would seek advice from Medical Services. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 17 No resident was able to fully self medicate. Medication records were checked and found to be good with no gaps. The Deputy Manager said that she trained staff as to supplying the medication. It was again recommended that the pharmacist or recognised training body trains staff that deal with medication, to ensure that this is fully comprehensive. There was still no evidence that GPs had authorised the administration of homely remedies, though there was recording when remedies were issued to residents. The Deputy Manager said this would be followed up by asking for this authorisation by letter. Medication is securely locked away. The Annual Quality Assurance Assessment states that residents have GP access and they can self medicate if they are able. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents welfare is protected by the procedures of the home. Residents views are listened to and acted upon. EVIDENCE: ‘’ I think they would do something if I had a problem’’. The Complaints Book indicated that there have been no complaints made since the last inspection. The Commission for Social Care Inspection has also received no complaints regarding the service. The Complaints Procedure seen by the inspector reflects the National Minimum Standard in that it stated that any complaints would be properly followed up, though it now needs to be altered to indicate that the local Social Service Department in now the Lead Agency for dealing with complaints regarding residents care. The Deputy Manager said this would be followed up. A staff member was asked about whistle blowing procedures, and demonstrated a generally good understanding of the protection of residents from abuse and contact details of relevant outside Agencies. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Facilities are looking dated and need refurbishment. A good standard of hygiene is maintained. EVIDENCE: Residents said that they liked their bedrooms and they could have their things in them. ‘’I like my bedroom. Its got all my things in there. ‘’It will be nice when its decorated’’. Standards of cleanliness in the bedrooms were satisfactory. Redecoration had begun in one bedroom. The communal lounge/dining room/bedroom areas have been decorated to a generally satisfactory standard though appeared worn and dated. The Deputy Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 20 Manager said that she was in the process of getting a painter to decorate bedrooms to residents preferences as she acknowledged they are in need of redecoration and this will be carried out by the end of this year, which it needs to be as it was formerly said by management that it would be completed two years ago. New furniture has been bought for bedrooms which now needs to be fitted – the Deputy Manager said she had been waiting a long time for this to be done so she would get someone else to do it. The inspector was shown this flat pack furniture. The inspector looked at the bedrooms of residents and the communal areas. Some bedrooms did not have many personal possessions, pictures etc in them but this is how they have always been and residents appear satisfied with this provision. Headboards on beds are still in need of replacement as they were still worn. New furniture has been bought for the lounge so there is now a new sofa and easy chair. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. 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 dedicated staff group, but the staff shift system could put residents at risk and insufficient staff training may not meet residents needs. Recruitment practices need to be more thorough to protect residents from unsuitable staff. EVIDENCE: Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 22 The residents spoken with said they were happy with staff. ‘’Staff are good. They are my friends’’. ‘’All the staff are nice’’. There are generally two to three staff on duty when residents are in the home. The Deputy Manager said that the awake staff member at night has been reduced to splitting the shift to sleeping in as there is minimal residents activity at night though if this changed then this would revert back to a full awake staff on at night. As shown from the rota seen for the week of the inspection, staff shifts are still very long for the Registered Provider – over fourteen hours – and working sixty hours per week plus carrying out all seven sleeping in duties. This was found in the previous two years inspections and needs to be changed as it could well cause fatigue and impaired staff performance. Staffing consists of a very small group of two management staff plus two care/catering staff. The only other staff are agency staff. The home appears to be permanently in this situation of having to rely on Agency staff. The Deputy Manager said that new staff members were being sought with an advert being placed in the main local newspaper. However the wording of the advert could well put off a large proportion of candidates applying as it specifies that trained staff were preferred. The Deputy Manager said she would look at the wording of the advert to encourage people to apply. Agency Staff records now had Criminal Records Bureau / Protection of Vulnerable Adults numbers though other important documentation (copies of references) were not currently available – this was to be followed up by the Deputy Manager. Records for one staff could not be located. The Deputy Manager said she would follow this up with the Agency concerned. There is currently only one staff with a National Vocational Qualification level 2 qualification, which does not meet the 50 target of the National Minimum Standard. There was evidence on file that staff have had training in a range of topics – Health and Safety, Insulin Administration, Moving and Handling, Food Hygiene, First Aid, Epilepsy, Health Facilitation, Learning Disabilities training, etc but not all staff had received all aspects of training. A Training Matrix was not available to show which staff had been trained in which issue. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37.39,42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents do not have full protection regarding health and safety. EVIDENCE: Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 24 One resident said, ‘’Things run smoothly here’’. The Registered Manager does not have management training though the Deputy Manager said she is to enrol on a Registered Managers Award training course. There is a Quality Assurance system but this has not been completed or includes residents views or the views of others – GPs, Nurses, relatives etc on the way the home is run. This needs to be carried out and for the Registered Provider to analyse the results of surveys and include this information in the home’s information for current and prospective service users. There were no supervision records for staff to prove that staff are supported to provide a high quality service. Residents monies records were viewed which were up to date, though again no transactions were signed by the resident and staff or two staff. The Deputy Manager said this would be carried out. The Annual Quality Assurance Assessment states that fire safety is followed but the inspector found that fire doors to the lounge and kitchen were again propped open. The Registered Provider again said that the fitted fire enclosures were not working and that residents propped open doors. The inspector said fire doors must be kept closed unless the fire closures were properly working, and issued a legal notice to deal with this. A staff member was asked as to the fire procedure and was generally aware of this though missed out some aspects. The Deputy Manager said this issue would be put in place. Fire records showed that regular testing of fire bells and emergency lighting testing was in place though there was a three month gap in doing this monthly check, and there are regular fire drills. A fire risk assessment is in place. There was a Risk Assessment for hot radiators found on the Care Plan of one resident. Radiator covers to protect residents from heat injuries have not been fitted as the Risk Assessment concluded that residents can be protected by putting furniture in front of radiators. This needs to be reviewed as to its effectiveness. The hot water temperature was measured and found to be 50.9c in a second floor bathroom, posing a scalding risk to residents. The National Minimum Standard is close to 43c. An Immediate Requirements Notice was served to deal with this. The Deputy Manager locked the bathroom in question and said that a plumber would be contacted to deal with this. There was a chart in place recording hot water temperature but no servicing in place to deal with the valve that regulates the temperature. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 25 Health and Safety Policies and Procedures and Risk Assessments were in place but had not been reviewed for up to nine years. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 1 13 3 14 X 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 1 3 2 X X 1 X Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 27 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 OP12 Regulation 16 Requirement That an Activities Programme is drawn up and carried out in order to provide relevant activities for residents. Health and safety systems must ensure that residents are protected from all risks including protection from hot water temperatures and a review of all health and safety Risk Assessments to ensure residents are fully protected from all assessed risks. Furnishings and décor needs to be upgraded to ensure they produce a homely atmosphere for residents. Timescale for action 21/09/08 2. YA42 23 (4) 21/08/08 3. YA24 16 21/12/08 4. YA32 18 That the length of staff shifts and 21/09/08 the number of hours worked per week is reviewed, to ensure that staff shifts are not excessive to ensure all staff are not unduly fatigued so that there is not impaired staff performance. Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 28 4. YA34 18 Staff recruitment procedures must be in place in respect of references and to ensure that residents are always protected from unsuitable staff. A staff training programme must be delivered to provide relevant training to all staff. The Registered Provider must show fitness to manage through health and safety systems protecting residents from all fire risks. 21/08/08 5. YA35 18 02/02/08 6. OP31 10 22/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA17 Good Practice Recommendations Care Plans and daily records must be kept up to date to ensure that they are relevant to residents needs. It is recommended that how food is provided to residents is reviewed, that food records record the variety of vegetables and that a dessert is always offered for main meals. Staff medication training needs to be delivered by a professional body and the GP needs to authorise homely remedies to ensure residents are fully protected. The Complaints Procedure needs to be amended to ensure residents can effectively make a complaint. That the home ensures that all staff are fully trained in all relevant issues. 3. YA20 4. 5. YA22 YA32 Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 29 6. YA37 That management systems be reviewed to ensure that all Requirements needed to ensure the proper running of the home are fully adhered to fully protect the welfare of residents. That the Quality Assurance system, including residents and other relevant parties views, is carried out for 2008 to ensure that services are of a high quality. 7. YA39 Winthorpe Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Residential Home DS0000006448.V368805.R01.S.doc Version 5.2 Page 31 - 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!