Inspection on 31/01/06 for Winton Nursing Home

This inspection was carried out on 31st January 2006.

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.

Other inspections for this house

Winton Nursing Home 20/11/08

Winton Nursing Home 30/04/08

Winton Nursing Home 01/05/07

Winton Nursing Home 21/11/06

Winton Nursing Home 18/08/05

Winton Nursing Home 23/11/04

Winton Nursing Home 17/06/04

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 Winton Nursing Home Wallop House Nether Wallop Nr Salisbury Hampshire SO20 8HE Lead Inspector Mrs Pat Trim Unannounced Inspection 31st January 2006 10:15 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 Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 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. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Winton Nursing Home Address Wallop House Nether Wallop Nr Salisbury Hampshire SO20 8HE 01264 781366 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) Mrs Evelyn Mary Cornelius-Reid Care Home 45 Category(ies) of Dementia - over 65 years of age (45), Old age, registration, with number not falling within any other category (45) of places Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th August 2005 Brief Description of the Service: Winton nursing home is set in the village of Nether Wallop, within easy reach of local amenities at Stockbridge and Andover. The home is registered as a care home with nursing and may accommodate up to 45 service users who are older persons or older persons with dementia. Accommodation is provided on two floors with lift access. The main house accommodates those who require assistance with physical care, whilst the annex accommodates those who have dementia. There are 35 single and 5 shared rooms. There is extensive communal space with several lounges, a garden room and dining room. There is a large landscaped garden. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second statutory inspection for the year 2005/2006, as the previous inspection was on 18th August 2005. However, as that inspection did not generate a report, the purpose of this inspection was to assess all the key standards and to monitor compliance with the requirements of the inspection carried out on 23rd November 2004. The inspection was unannounced and completed by one inspector in 7 hours. A courtesy call was made to the home on the morning of the inspection to inform them of the proposed inspection, so that a member of the management team could attend if they wished. During the inspection there was an opportunity to speak with 5 residents, 6 staff and 2 visitors. A partial tour of the premises was undertaken and a random selection of documents reviewed. Information contributing to this report was also gathered from the pre-inspection questionnaire, completed by the registered manager and comment cards, received from residents and relatives. During the inspection it was established that the people who lived in the home liked to be referred to as residents. This term will be used throughout this report. Since the last inspection the registered manager has left and a new manager has been appointed. An application to register the new manager is shortly to be sent to the commission but at present there is no registered manager in post. What the service does well: Residents and relatives expressed their satisfaction with the level of care provided and felt staff worked hard to provide an excellent service. Comments included ‘its well run’ and ‘everybody is friendly and respectful’. The home has a relaxed and calm atmosphere and provides a comfortable environment. Relatives said they felt comfortable visiting and were confident they could be involved in supporting their relative. They said communication was excellent and they were kept fully informed of their relative’s well being. Staff have a good knowledge of resident’s individual needs and care plans identify abilities as well as needs, so that staff see their role as supporting residents to maintain their independence as well as providing care. Residents and relatives said the food provided was of a high standard, with plenty of fresh vegetables and fruit and homemade cakes and puddings. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply. The comprehensive assessment, completed prior to admission, makes sure that a placement is only offered to residents whose needs can be met. EVIDENCE: The files for three residents, recently admitted, were case tracked. Each of these contained a comprehensive assessment, completed prior to admission. Where it was not possible to visit the prospective resident, for example when someone moved to the home from overseas, the assessment had been completed by talking with the manager of the resident’s current care home, and getting information from relatives. The pre admission assessments identified any areas of potential risk, such as challenging behaviour, MRSA infection or high risk of falls. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Care plans identify resident’s individual abilities and needs and this ensures staff have the information they need to provide support in the way each resident wishes. Residents’ health care needs are well monitored which ensures they receive the health care they need. The home’s policy and procedure in respect of the management of medication protects residents from the risk of error. Staff receive training and guidance that enables them to uphold residents’ rights to privacy, dignity and respect. EVIDENCE: Three care plans were seen. These gave staff guidance on each person’s abilities and needs in all aspects of their personal care and daily living. There was evidence that they were being reviewed on a monthly basis and amended where needs had changed. Assessments identified areas of physical risk, such as falls, with guidance for staff to follow to minimise the risk. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 10 However, issues of risk relating to challenging behaviour were not being addressed. On one file the pre admission assessment had identified this as a possible risk. This had not been carried forward to the care plan and there was no action plan to help staff minimise the risk. The resident had settled well and there had been no evidence of the issues identified in the assessment, but staff were advised a risk assessment should have been completed and a possible management plan discussed. The management of the home said they were aware of the need to develop skills in working with potential challenging behaviour and had booked a course for staff to attend. Staff were able to demonstrate their understanding of individual resident’s abilities and needs. They said they got information about changing needs from care plans, daily records and the handovers that took place at the beginning of each shift. Residents said they were able to see their doctor when they wished. Daily records showed that residents had access to a wide range of health care professionals and that doctors’ visits were requested if there was concern. Two requests for doctor’s visits had been made on the day of the inspection and staff confirmed part of their role was to inform the manager if residents appeared unwell and needed to see the doctor. Care plans evidenced that referrals to appropriate health care professionals were made to meet individual need. The home had a policy and procedure for the safe handling of medication that gave staff guidance on how to protect residents. The deputy manager said that only qualified staff were permitted to dispense medication. A member of staff described the daily routine which evidenced her knowledge of the home’s procedure. She confirmed the medication administration record was signed after each person had been given their medication. This minimised the risk of accident. The deputy manager said there was an arrangement with the local surgery that unused drugs could be returned to them. A written record was kept. Verbal and written feedback from residents evidenced they felt staff treated them with respect. They said they were asked on admission how they would like to be addressed and this information was recorded on their care plans. Staff said they believed it was a vital part of their job to enable residents to feel they were treated with dignity and respect. They were observed throughout the inspection knocking on doors and waiting for permission to enter. All bedroom doors have been fitted with locks so residents can have privacy if they want it. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Staff knowledge of individual resident’s social needs enable them to provide appropriate mental stimulation for those who are mentally frail. However, residents who are more able could benefit from the provision of more social opportunities. The welcoming atmosphere in the home enables relatives to feel comfortable about visiting residents whenever they wish. The culture of the home ensures that residents are able to make choices about how they spend their day. Meals are of a high standard and ensure that residents are able to have food they enjoy whenever they want it. EVIDENCE: Staff demonstrated they had a good knowledge of the social need of residents who had limited verbal communication. Staff were seen assisting residents by sitting them where they could see out of a window ‘because they like to watch the birds’, in front of the piano ‘because she likes to play every day’ or in front of a table with book and pencils ‘because she likes to draw’. Those who wished to read had access to library books, which were changed each month, or their Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 12 own newspapers. On the day of the inspection, a visiting minister called to take Holy Communion and residents said he also visited residents in their own rooms. There are ‘pat dog’ visits every week and seasonal activities are arranged such as garden parties, lunches and visits from local schools to sing carols. However, feedback from some residents indicated that they felt social activities were limited. Some felt this was due to staff shortages, especially at the weekends. The home’s administrator said the home had been short of staff in the weeks leading up to Christmas, but that recent appointments had improved staff provision. It was recommended that current provision of activities should be reviewed and feedback sought from residents about what they would like. Verbal and written feedback from relatives evidenced they felt very much included by staff in the care of the resident. Some visited almost daily and said they were always made welcome. They also felt that staff communicated well and kept them informed of anything affecting the wellbeing of the resident. They were invited to contribute to the care plan by providing a life history and information about a resident’s particular needs, likes and dislikes. Staff said how important they felt it was that residents were able to make choices about how they lived their lives. They believed an important part of their role was to ensure residents were supported to maintain their independence. They gave examples of how they achieved this in practice by listening to what residents wanted and by enabling to make choices about what time they got up, went to bed or chose to wear. Residents said they felt able to make choices. For example, if they had always got up late, they were able to continue to do so in the home, with staff helping them to get up at the time they wished. Care plans identified what residents could still do for themselves, for example, choosing their own clothes each day, or washing their face and hands. Feedback from residents and relatives evidenced that the majority felt the meals provided were very good. A choice of main meal was not offered, but the cook said residents could have an alternative if they wished. Residents confirmed this and said there was a wide choice of evening meal. The current system for recording meals was not sufficient to demonstrate a planned approach to meal provision. The cook said she decided at the beginning of each week what meals would be provided and ordered fresh food accordingly. Only minimal frozen food was ordered and there was evidence that a wide range of fresh meat, fruit and vegetables were supplied. However, there was no weekly menu plan available. A daily record was kept of the choices available for the evening meal, and what had been chosen by each resident, but there was no detailed record of what main meal was provided or Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 13 if anyone had chosen an alternative. This was discussed with the cook, who agreed to review current practice, to introduce a menu plan for the home and to keep a record of any alternatives chosen by residents to the main meal. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has robust complaints procedure that enables residents to be confident their concerns will be listened to and addressed. The in house procedure for the protection of vulnerable adults is inaccurate and staff do not have sufficient knowledge of the adult protection procedure to ensure residents are protected from the risk of abuse. EVIDENCE: The home had a complaints policy and procedure. The administrator said a copy was given to everyone on admission. Residents and relatives said they were aware of the complaints procedure and would feel able to use it if necessary. They were confident they could take any concerns to the management of the home and that they would be resolved. The home had a system for recording complaints but none had been received since the last inspection. The commission had not received any complaints in respect of the home. Four staff were asked about their knowledge of the adult protection procedure. Two were care staff and two were qualified staff. They were able to demonstrate they had some knowledge of adult protection procedures and those who had completed their National Vocational Qualifications (NVQ) had received some training. They understood their responsibility to report abuse in line with the whistle blowing procedure but were unsure of who would take the Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 15 lead role in co-ordinating an investigation into an allegation of abuse. The in house policy and procedure did not accurately reflect the guidance in the Hampshire adult protection procedure. The home had a copy of Hampshire’s adult protection procedure. The administrator said the need for further adult protection training had been identified and some had been arranged for this year. She agreed to review the procedure to make sure it complied with the guidance given in the Hampshire adult protection procedure. Staff were also being given the opportunity to attend training on working with challenging behaviour. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The home provides a safe, well-maintained environment that meets the needs of the residents who live there. It is clean and the systems in place make sure residents are protected from the risk of infection. EVIDENCE: Following requirements made in the inspection report of 23rd November 2004, a risk assessment for the building had been completed. A risk assessment of ground floor windows had been carried out and those that were identified as a possible risk to residents have been restricted. The nurse call system has been extended so that help may now be called from all communal areas. A fire officer from Hampshire Fire and Rescue Service visited the home on 9th January 2006. There were no requirements from his report. The administrator said there was a routine programme for the maintenance of the home. Renovations planned for this year included replacing the carpet in the annex lounge and redecorating the ground floor hallway and sluice. On the day of the inspection the home was clean and there were no unpleasant smells. The home employs a domestic team to carry out all heavy duty Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 17 cleaning and care staff are only responsible for making beds, emptying and cleaning commodes. The home had a policy and procedure for infection control and staff were able to demonstrate their knowledge of it. Appropriate equipment such as soiled linen bags, incontinence pad bags, disposable gloves and aprons were readily available throughout the home. Communal bathrooms and toilets had liquid hand wash, disinfectant hand wash and paper towels. A laundress is employed to do all the home’s washing. The washing machines have programmes for disinfecting soiled linen. Written guidance on which programmes should be used is kept in the laundry. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Qualified staff and care staff are provided in sufficient numbers to be able to meet the needs of current residents. They are actively encouraged to achieve qualifications that enable them to develop their abilities to meet residents’ needs. The current recruitment procedure is inadequate and fails to protect residents. A better system of monitoring staff training needs would enable the registered manager to provide a training plan that ensures staff are able to maintain and develop their skills. EVIDENCE: The administrator said that the recent appointment of three more qualified staff and extra care staff meant the home was now more able to maintain the staffing levels they had identified as being needed. Feedback from some residents, relatives and staff showed they felt the home did not always have the staffing levels needed, but some of this information had been obtained before the new staff were in place. The current staffing levels were 2 qualified and 6 care staff on duty in the main home from 8 a.m. till 2 p.m., and 1 trained and 3 care staff from 2 till 9 p.m. In the annex there is 1 trained staff and 3 care staff from 8 a.m. till 9 p.m. This is the minimum staffing level the home provides and these numbers are often exceeded. Night staffing levels comprise 1 qualified and 3 care staff for both areas of the home. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 19 In the inspection report for November 2004, attention was drawn to current system for recording who had worked in the home. This was difficult to follow. Since then a rota has been provided, but there was evidence that names were still being ‘tippexed’ out and this practice must stop as the regulations require a clear record of who works on each shift. In addition the home employs domestic staff for cleaning, cooking and laundry. The home promotes a culture where staff are supported obtain their National Vocational Qualification (NVQ). The administrator said that 13 staff have NVQ 2 or above and 2 were just starting it. The home currently employs 32 care staff so the requirement of 50 of staff having NVQ 2 or above is nearly met. Staff are encouraged to obtain this qualification by being supported to study and being given more responsibility and pay for achieving it. The recruitment procedure had not been consistently followed and residents were not protected. The files for two staff, recently appointed were seen. One contained a Criminal Records Bureau disclosure (CRB) that the applicant had brought with her from her previous employment. These have not been portable since July 2004, as a new one is needed so employers may also check the Protection of Vulnerable Adults (POVA First) list. There was also no application form, no references and no record of an interview. The administrator explained that the applicant had previously worked in the home. She was advised that these checks must still be completed for every applicant. This member of staff had not yet started work in the home. The second file contained a completed application form that showed there were gaps in the person’s employment. She had brought her own references when applying for the post and her CRB and POVA First checks had been applied for but had not yet been received. She was already working in the home. The administrator was informed that no staff could work in the home prior to these checks being completed. She was advised to refer to the latest guidance on POVA First. The administrator said that recent changes in the home had meant a delay in the implementation of staff supervision and annual appraisal. The acting manager had developed an appraisal tool and would be using this to identify training needs for the year. Training arranged for this year so far included moving and handling, wound care, infection control, challenging behaviour, food hygiene and adult protection. One of the qualified staff was going to attend a train the trainers course in moving and handling so she could provide training and assessment to new staff as part of their induction. Staff confirmed they had been able to attend basic training during the past year and had been able to register their interest in the courses booked for this year. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 20 Staff said they had to complete an induction course before being able to work unsupervised in the home. A care staff who has achieved an NVQ 3 is appointed as their mentor during induction. A copy of the induction programme was seen. This was completed over a three-month period. It was recommended that each section be signed and dated by the care staff and assessor. It was also recommended that the provider contact Skills for Care to ensure the current induction complied with guidance for the induction of care staff. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The registered manager has a good support network that enables her to provide a well-managed service that meets the needs of residents. The current systems in place to audit the quality of the service are not sufficiently developed to enable all residents to give feedback about the service they receive. The practice of the home in respect of managing resident’s money ensures they are protected against the risk of financial abuse. Systems are in place that ensure the health and safety of residents are protected. EVIDENCE: The registered manager who had been responsible for the day-to-day management of the home had left in July 2005. Someone who had previously worked in the home as the deputy had recently returned to take up the post of Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 22 manager and was applying to the commission for registration. She is completing her registered managers’ award. The registered manager is supported in her role by a management team who are responsible for the dayto-day running of the home. The provider visits the home at least weekly. Residents and relatives felt the home was well run and that the needs of residents were always considered when decisions about the day to day running of the home were made. The administrator said she visited residents on a daily basis to make sure they were well and had no problems, but there was no formal system in place to obtain their feedback about the service. Residents’ or relatives’ meetings were not held. Staff said meetings were irregular. Some issues could be raised during handover or problems could be discussed with the sister in charge of the shift or the manager. The administrator said the provider visited the home at least weekly but the monthly visits required by Regulation 26 had not been carried out on a monthly basis and no reports had been given to the manager. A requirement was made that these visits must be made and written feedback kept in the home so that the registered manager is aware of the comments and requirements made by the provider. There was a discussion between the administrator and inspector about the need to develop a more effective quality audit system so that the provider could demonstrate how the views of the residents impacted on the day-to-day management of the home. The administrator said it was the policy of the home not to hold money on behalf of residents and that those who could not manage their own had to arrange for someone to do it for them. The home pays for any bills incurred by residents who do not manage their own money and then invoices the family for payment on a monthly basis. This includes sundries such as hairdressing and chiropody. Staff receive mandatory training such as food hygiene, infection control and moving and handling. Fire training is provided on induction by the management of the home and two fire training sessions a year are provided by an outside trainer. Regular fire drills are also held. The current system for recording staff fire training does not demonstrate how staff unable to attend training sessions receive alternative instruction. The person responsible for fire safety within the home agreed to review the current system. The fire log book showed that regular testing of fire equipment was carried out and that it was regularly serviced. The provider has made arrangements for the regular servicing of equipment and utilities. This was evidenced by Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 23 information given in the pre-inspection questionnaire, a random selection of records seen during the inspection and observation of equipment during the tour of the home. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 25 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 OP15 Regulation 17(2) Requirement Timescale for action 01/03/06 2 OP18 13 3 OP30 18(2) 4 OP29 19 A menu plan must be available to demonstrate that service users have access to a nutritious and balanced diet. The in house procedure for the 25/04/06 protection of vulnerable adults must be reviewed to ensure it complies with the guidance in Hampshire’s adult protection procedure. All staff must receive formal 01/06/06 supervision at least six times a year. (Previous timescale of 31/01/05 not met) No member of staff may work in 01/02/06 the home unless all checks are made, including obtaining references, having a completed application form on file as well as obtaining a Protection of Vulnerable Adults (POVA First) and Criminal Records Bureau (CRB) check. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 26 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 OP12 OP33 Good Practice Recommendations That feedback is obtained from residents about what activities they would like to see provided. That systems are developed that enable the provider to effectively audit the quality of the service provided. Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Winton Nursing Home DS0000012032.V280614.R01.S.doc Version 5.1 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. 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