Care Home: Winthorpe Hall Care Home

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What the care home does well The statement of purpose complies with the Care Homes Regulations, and a copy is supplied to people at the home or their representatives on request to help people determine the suitability of the home in meeting their needs. People said their private and communal areas within the home are kept warm and comfortable. People said their health care needs are met, that they are afforded appropriate levels of privacy and dignity and receive their medication as prescribed. People said they are happy with the standard of cleanliness throughout the home. People said that they are provided with the opportunity to express their opinions, wishes and preferences. People are protected by the homes recruitment policy and practices. What has improved since the last inspection? Recreational activities are provided within the home and opportunities are available for people to interact within the broader community. People said that the quality of food has improved and they are now provided with drinks and snacks as required. Developments have been in relation to the management structure which is now effective in supporting staff in promoting the health and wellbeing of people. What the care home could do better: At the previous inspection it was highlighted that policies and procedures had not been updated or reviewed. Some progress has been made in addressing the concern but the manager stated that the revision of some policies and procedures remains outstanding. The care planning process could be further developed to ensure care plans are "person centred". All radiators should be fitted with guards to promote the safety of people at the home. CARE HOMES FOR OLDER PEOPLE Winthorpe Hall Care Home Gainsborough Road Winthorpe Newark Nottinghamshire NG24 2NR Lead Inspector Steve Keeling Unannounced Inspection 9th February 2009 11:00 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.V374148.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.V374148.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 winthorpeHall.co.uk Mr R C Pountney 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) 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.V374148.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered persons may provide 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. 27th August 2008 2. Date of last inspection Brief Description of the Service: Winthorpe Hall is a privately-owned care home registered to provide accommodation 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 and general shop, parish church, village hall and a 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 public houses. The accommodation consists of 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, gardens, which provide people with a tranquil, safe area to walk and sit in. There is a large car parking area for staff and visitors. The fees range from £350:00 to £420:00 each week, which does not include hairdressing and chiropody services or newspapers and magazines. The provider also makes a charge of £7:00 per hour for escorting people to hospital. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 5 Information about the home can be obtained from the manager and via the internet. A service user’s guide is also available in the foyer of the home which contains the last report from the Commission for Social Care Inspection. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who use the service and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This is the second unannounced inspection to be performed within this inspection year. At this inspection we assessed areas, which were assessed as adequate or poor from the previous inspection, performed on the 27th August 2008. One inspector conducted the unannounced visit. The main method of inspection used was called ‘case tracking’ which involved selecting people who use the service and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. The manager and members of staff were spoken with as part of this visit. Medication management was also inspected to form an opinion about the health and safety of people at the home. A partial tour of the building was undertaken which included a sample of people’s bedrooms, to make sure that the environment is safe and homely. A review of all the information we have received about the home since the last inspection was considered in planning this visit and this helped decide what areas were looked at. Additional information was used to determine the outcome of this visit, which included information provided by the registered provider within an Annual Quality Assurance Assessment. We also used four responses from the ten “have your say” service users surveys which were distributed people at the home prior to this inspection. What the service does well: Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 7 The statement of purpose complies with the Care Homes Regulations, and a copy is supplied to people at the home or their representatives on request to help people determine the suitability of the home in meeting their needs. People said their private and communal areas within the home are kept warm and comfortable. People said their health care needs are met, that they are afforded appropriate levels of privacy and dignity and receive their medication as prescribed. People said they are happy with the standard of cleanliness throughout the home. People said that they are provided with the opportunity to express their opinions, wishes and preferences. People are protected by the homes recruitment policy and practices. What has improved since the last inspection? What they could do better: At the previous inspection it was highlighted that policies and procedures had not been updated or reviewed. Some progress has been made in addressing the concern but the manager stated that the revision of some policies and procedures remains outstanding. The care planning process could be further developed to ensure care plans are “person centred”. All radiators should be fitted with guards to promote the safety of people at the home. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 8 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.V374148.R01.S.doc Version 5.2 Page 9 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.V374148.R01.S.doc Version 5.2 Page 10 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): 1,3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with information about the home, which helps them to make an informed decision about the suitability of the home in meeting their needs. Assessments are performed prior to moving into the home, to make sure their needs can be met. EVIDENCE: At the previous inspection, performed on the 27th August 2008, the outcome, area was assessed as good and the following conclusions were made at that time. The information provided by the registered manager in the Annual Quality Assurance Assessment stated, “We ensure that service users are aware of our Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 11 web page winthorpeHall.co.uk and can view our Statement of Purpose and our Service Users Guide. We provide short term care and all new residents have a settling in period of a month, each resident has a written contract”. We examined the service user guide which is available to all people in the foyer of the home, it contained the last key inspection report from the Commission for Social Care Inspection, a statement of purpose, a copy of the complaints procedure, a residents charter, an overview of home, aims and objectives, terms and conditions of residency, information about what is or is not included in the fees and a Whistle Blowing policy. Information provided by the manager in the Annual Quality Assurance Assessment stated “We have in place pre-admission assessments using recognised assessment tools to aid this process”. We examined the pre admission assessment documentation, it showed that it would provide the opportunity to identify peoples needs, in relation to promoting their health and wellbeing. The assessment process also uses information provided by other agencies, such as Adult Social Care and Health, when available. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The healthcare needs of people who use the service are recorded and met. Medication is managed appropriately and people who use the service are afforded appropriate levels of privacy and dignity. EVIDENCE: We asked people who use the service if they felt their needs are being fully met. Comments included “Yes all the time” and “I am very happy here, yes we are well looked after”. We spoke to two people who were sitting in the lounge area, both said they are very satisfied with the quality of care they receive and expressed no concerns whatsoever. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 13 The Annual Quality Assurance Assessment states that “we have a computerised care planning tool and each service users care plan is updated monthly and printed out for residents and family to view. In addition, we get the family to review and sign the care plan”, records were available to support this. The care plans of people who use the service contain sufficient information for staff to carry out the tasks required to meet peoples needs. Staff said that they have access to the care plans at all times for guidance and reference. The care plans include risk assessments to ensure risks are identified and addressed. This includes risk assessments completed for people who are at risk of falls. The electronic care planning and risk assessment procedure prompts staff to review the documentation on a monthly basis to ensure that changing needs are identified and met. The care planning documentation would benefit from being more “person centred”, the manager confirmed that she is in the process of discussing person centred care planning with care staff in an attempt to develop the care planning process further. The Annual Quality Assurance Assessment states, “All service users have access to doctors, district nurses, opticians, and community health services”. Records showed and people said that they do have access to General Practitioner’s, District Nurses, Chiropodists and Optical Services. Two community nurses were visiting people on the day of the inspection we spoke to one nurse who said staff at the home refer people to the community nursing tem in a timely manner. At the previous inspection the administration, storage, disposal and recording of drugs were inspected and assessed as safe. At this inspection we asked people living at the service if they get their medication on time. Responses included “Yes, all the time, they are very good in that area”. We briefly observed the morning medication round. A senior carer who confirmed that she has had training in the Safe Handling of Medicines, administered the medication in a safe manner. The Medication Administration Records (MAR) were filled out correctly which demonstrated that medication was administered appropriately. We asked people “Do staff listen and act on what you say”. All people spoken with were very complimentary in relation to the staff at the home, comments included “the staff are wonderful here, they are all so kind” and “yes my respect is always maintained”. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 14 We observed people being assisted to have their meals in a kind, considerate and un-rushed manner, offering assistance when required whilst promoting peoples respect and dignity. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recreational activities are provided within the home and opportunities are available for people to interact within the broader community. People expressed satisfaction with the quality and variety of meals provided. EVIDENCE: Information received in the Annual Quality Assurance Assessment stated; “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 monthy lunch club outings”. The “have your say” pre inspection questionnaire asked people “Are activities arranged in the home that you can take part in” two respondents stated “always” one respondent stated “usually” and one respondent stated “sometimes”, one respondent commented “various activities are offered”. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 16 We asked people who use the service about the social activities provided. A person said “I am very satisfied, we have games of bingo, sometimes play cards, guest entertainers come, all of which I enjoy”, another person said “we can do what we like, the staff respect our wishes, sometimes I cannot be bothered with joining in, but that OK”. Social Activities are advertised in the lounge area for each day of the week. People who use the service and memebrs of staff confirmed that the planned activities take place which includes Bingo, quizzes, manicure sessions, guest entertainers and singsongs. People also confirmed that that they attend a luncheon club in the local community centre, which they enjoy. People told us that they go to bed when they want to and get up when they wish. People also confirmed that the service is flexible in meeting their needs. One person said “it’s our home we can do what we want really”. People told us that the manager promotes an open door policy in relation to relatives and friends visiting the home. People confirmed that their relatives and friends are made very welcome by all the staff at the home and they are offered drinks and meals. The “have your say” pre inspection questionnaire asked people “Do you like the meals at the home” three people stated “usually” and one person stated “always”. One person commented “the menu varies and there are choices daily”. We asked five people if they liked the meals at the home. The responses were very positive and included “they have improved recently, yes they are very nice” and “always nice and hot, a good choice as well”. We asked people if they are provided with drinks and snacks throughout the day and before bedtime, once again, all people spoken with expressed satisfaction in this area and no concerns were expressed. On the day of the Inspection the lunchtime menu consisted of poached Salmon with mash potatoes and fresh vegetables or Quench Lorraine with roast potatoes and fresh salad, followed by a choice of puddings. The meals were well presented and looked very appetising. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service felt confident that any complaints or concerns they might have would be addressed effectively and staff have now received training in Safeguarding Adults to promote peoples safety. EVIDENCE: The Annual Quality Assurance Assessment states that “We have a complaints procedure that works well and all service users and families are well aware of how to use it.” A complaints procedure is displayed in the foyer of the home and the procedure is also supplied in the service user guide in the foyer of the home. The Commission for Social Care Inspection has not received any complaints about the service since the last Inspection took place and the manager stated that no complaints had been received since the last unannounced inspection was performed on the 27th August 2008. The “have your say” pre inspection questionnaire asked people “Do you know how to make a complaint” all four respondents stated “yes”. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 18 We asked people “Do you know how to make a complaint?” all respondents said “yes”. We also asked if people felt safe in the home, once again all respondents stated, “yes”. At the pervious inspection we identified shortfalls in relation to staff training in Safeguarding Adults. The manager has addressed the shortfall in a timely manner as records now show, and staff confirmed, that training in this area has been provided by an accredited training agency. We spoke to a member staff to determine her level of understanding in this area. The member of staff demonstrated a good level knowledge of Safeguarding Adults procedures; in addition the member of staff said that the revised Nottinghamshire Safeguarding Adults policy is available at the home if further guidance is required. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a well-maintained environment, which is comfortable, clean and safe. EVIDENCE: Information provided in the Annual Quality Assurance Assessment stated, “We strive to ensure that service users live in clean, hygienic and comfortable surroundings.” The “have your say” pre inspection questionnaire asked people “ is the home fresh and clean”. All respondents stated, “Yes” and one person commented, “a great deal of attention is paid to this”. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 20 We asked people if they are satisfied with the standard cleanliness in the home, they all said they were very happy with the standards of cleanliness and confirmed that their bedrooms are cleaned on a regular basis, as are the communal areas in the home. We did a partial tour of the building, which included people’s bedrooms, communal areas and the kitchen facility. All areas were well maintained, clean, fresh and warm. People’s bedrooms were homely and personalised. At the previous inspection we sampled the water outlet temperatures in the bedrooms and they were satisfactory it was also noted that window restrictors and nurse call systems were in place to promote people’s safety. At this inspection it was noted that radiators in some bedrooms, which were not in use at the time of the inspection, did not have radiator guards in place, which could present a risk of burns to people. Staff said that gloves and aprons are worn at all times when providing personal care to promote infection control; we observed that gloves and aprons were available in bathrooms and staff were using them appropriately. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are protected by staff recruitment practices. Staff have received training in the work they are to perform, thus promoting peoples health and wellbeing. EVIDENCE: On the day of the visit, fifteen people were in residency at the home, being supported by one senior carer, three care assistants, the manager, a cook and two cleaners. The “have your say” pre inspection questionnaire asked people “ Are staff available when you need them”, three respondents stated “always” and one respondent stated “usually”. We asked people “Are the staff available when you need them“ all the respondents stated “yes”. Comments included “yes, there is always someone available, they are very good and hard working” and “ I think so, there is always someone about”. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 22 Staff files showed that recruitment processes are effective in promoting safety. Staff files contained, Protection of Vulnerable Adult checks, Criminal Record Bureau Checks, an application form and two written references, all of which had been obtained before employment commenced. At the previous inspection it was shown that not all staff had received an effective induction process. The manager has addressed this concern, all staff, including staff that have been in employment at the home for some time have now undergone the induction process to promote the health and well being of people at the home. The manager confirmed that the present induction process does not utilise the “Skills for Care” common induction standards. At the previous inspection it was shown that not all staff had received the required training to perform their duties. At this inspection we were provided with a staff-training matrix, which showed that a comprehensive staff-training programme has now been provided. Staff confirmed that the training had been provided and felt that they had the skills and knowledge to promote peoples safety. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management structure is effective in supporting staff to promote the health and wellbeing of people at the home. EVIDENCE: The “have your say” pre inspection questionnaire asked people “Is there anything else you would like to tell us”, the two responses were , “No comment needed really, I’m quite content with everything” and “very happy”. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 24 The registered manager has worked at the care home for several years and has achieved a degree level Registered Managers Award (RMA). The manager has made significant progress in addressing the requirements made at the previous inspection. At the previous inspection it was established staff supervision was not always performed. At this inspection records showed and staff confirmed that staff supervision now takes place on a bi monthly basis. A member of staff said that she values the supervision sessions and felt they were effective in promoting good care practices at the home. At the previous inspection staff told us that they were aware that policies and procedures are available in the home but are not aware of there location, and they are not used. Furthermore the Annual Quality Assurance Assessment shows that Policy documents have not been up dated on an annual basis. Information provided by the manager showed that good progress has been make in updating the homes policies and procedures with an expectation that all the policies and procedures will be updated by the end of March 2009. In addition a member of staff said that she was aware of the location of the policies and procedures and would refer to them if required. At the previous inspection it was established that a process is in place to determine the satisfaction of people living at the home. Regular “residents forums” are held to give people the opportunity to express their wishes and to comment on the service they receive. People spoken with confirmed this and said “we have meetings where we are asked what we want to do”. As mentioned earlier in the report (OP 30) the manager has responded in a timely manner to requirements set by the Commission for Social Care Inspection in relation to staff training and records show that an extensive staff training programme has been performed. Secure facilities are available for people to store their spending money at the home. Records showed that the process of recording financial transactions has been recently reviewed to protect people from financial abuse. At the previous inspection it was established that the health, safety and wellbeing of people who use the service is promoted by the provision of effective routine maintenance. Information provided within the Annual Quality Assurance Assessment shows that an up to date electrical circuit safety certificate and gas certificate is in place. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 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 3 x 3 x 2 3 Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 26 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 OP37 Regulation 12 (1) (a) Requirement To promote the heath and well being of people the registered person must ensure that the remaining policies and procedures, that have not been revised, are updated as a matter of priority. Timescale for action 01/04/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations To promote the health and wellbeing of people the registered person should ensure that the care planning process is further developed to ensure care plans are “person centred”. To promote the health and wellbeing of people the registered person should ensure that all radiators are fitted with guards to promote the safety of people at the home. To promote the health and wellbeing of people the registered person should ensure that all new staff employed at the home are provided with an induction DS0000024670.V374148.R01.S.doc Version 5.2 Page 27 2 OP19 3 OP30 Winthorpe Hall Care Home process based on the “Skills for Care” common induction standards. Winthorpe Hall Care Home DS0000024670.V374148.R01.S.doc Version 5.2 Page 28 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. 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