Inspection on 25/09/07 for The Windbound

This inspection was carried out on 25th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Windbound 27/07/09

The Windbound 03/09/08

The Windbound 03/04/07

The Windbound 26/04/06

The Windbound 17/10/05

The Windbound 15/03/05

The Windbound 26/01/05

The Windbound 30/03/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Windbound Shepperdine Thornbury Sth Gloucestershire BS35 1RW Lead Inspector Paula Cordell Key Unannounced Inspection 25th September 2007 10:00 The Windbound DS0000043699.V349774.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 The Windbound DS0000043699.V349774.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. The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Windbound Address Shepperdine Thornbury Sth Gloucestershire BS35 1RW 01454 414888 01454 416724 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) Voyage Limited To be Appointed Care Home 12 Category(ies) of Learning disability (12) registration, with number of places The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate one named person aged over 65 years. The registration will revert to previous when that person leaves. 3rd April 2007 Date of last inspection Brief Description of the Service: The Windbound is a care home operated by the Voyage Group. It is registered by the Commission to provide accommodation and personal care for up to 12 men and women aged 18 - 65 years who have a learning difficulty. Residents have a diverse range of needs. The home particularly aims to cater for people who may challenge other services and who may display verbally and physically challenging behaviours. The home itself is situated on the bank of the River Severn. It is in a secluded spot, which would best suit those who prefer a calm and quiet environment. The home has three vehicles, which are used to support Service Users to access community facilities. The Windbound was once a public house, which has been converted into three individual flats separated by keypad systems. Ms Lesley Richings is the manager and as yet has to be registered with the Commission for Social Care Inspection. The fees for the home at the time of publishing this report range from £1,092 to £2,444 per week. The home is in the process of setting up an Email address. This was not available during this inspection visit. The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit as part of a key inspection. The purpose of the visit was to follow up the requirements from the Key inspection in April 2007 and a random visit in June 2007. In addition to monitoring the quality of the care provided to the individuals living at the Windbound. There have been no additional visits between April 2007 and this visit. However, the manager, the deputy manager and the operational manager were invited to the office of the Commission for Social Care Inspection for a meeting. The purpose of the meeting was to discuss what improvements could be made, to improve the service to the individuals living in the Windbound. The home has submitted an improvement plan and this was followed up during this visit to monitor progress. There have been no complaints received about the service. However, safeguarding adult procedures have been implemented in relation to two individuals living in the home. This has resulted in the systems in place to manage aggression being reviewed including expanding on information in the care documentation. The Commission for Social Care Inspection and South Gloucestershire Council are closely monitoring this. The inspection methods used included record checks, case tracking, a tour of the home and discussion with the deputy manager, four staff, and people who use the service. The home has been sending information in respect of regulation 37 notices of events affecting the well being of the people who use the service including incidents of aggression involving individuals living in the home. These were used as a focus for the site visit, along with the annual quality assurance selfassessment completed by the home for the last key inspection in April 2007 and comments from people who use the service (5), relatives (6) and visiting professionals (2). Surveys were not requested for this visit. The visit was conducted over a period of six hours and ended with structured feedback being given to the deputy manager. What the service does well: The home supports individuals with complex care needs, which include behaviours that challenge. It is encouraging that the environment is homely and furnished with ordinary domestic furnishings. Individuals are encouraged to make full use of the local community and daily outings are organised. The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home must ensure that they continue to work towards the National Minimum Standards and the requirements that have been made on previous visits. Individual’s contracts must be reviewed in relation to fees and personal allowances, which have recently changed. Individuals living in the Windbound would benefit from a written record on how they prefer to communicate, which will assist staff in ensuring a consistent approach. A referral to the placing authority for one individual must take place to ensure the home can continue to meet changing needs and ensure the safety of the others living in the home. Individuals must be confident that they have available to them a structured day care plan that is realistic and that sufficient staff are working to support them in their chosen pursuit. For staff to complete the Learning Disability Award Framework which will assist with skills to enable them to support the individuals living in the Windbound. People living in the home must be assured that the home is operating legally with a registered manager. The Windbound DS0000043699.V349774.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. The Windbound DS0000043699.V349774.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 The Windbound DS0000043699.V349774.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): 1,2,5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Individuals have information available to them in relation to the service provided at the Windbound. The Windbound supports individuals with complex care needs and behaviours that can challenge for the home to fully become a specialist service, training must be in place to fully meet the assessed care needs of the individuals. Whilst the contracts in place contain valuable information relating to the individual these are now out of date relating to finances and could be misleading. EVIDENCE: The statement of purpose and the service user guide have been read on previous visits to the home and were found to contain all the information as required by the National Minimum Standards and the Care Home Regulations. The information was written in plain English and included photographs. The deputy manager stated that much of the information is being reviewed to The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 10 ensure that it is accessible and a new computer package has been purchased to enable some of the documentation to be made available in symbols. The home presently has one vacancy. The statement of purpose clearly describes the admission process and the criteria for potential individuals that the home could support. The manager said that no new persons would move to the home until the Windbound has been refurbished. The deputy manager confirmed that the plans for developing the home into four separate flats were still being pursued as discussed during the visit in April 2007. Each flat would have a designated team of staff with the appropriate skills to support the individuals. It was hoped that the individuals would have clearer boundaries and live with people who have similar needs and abilities. Each flat would be self contained and would have separate facilities including a kitchen, lounge, bathroom and individual bedrooms. The Windbound is a service that supports individuals with complex and challenging care needs. During the last visit there were concerns raised about the training that was in place for staff to support the individuals in relation to challenging behaviour, mental health and autism. Staff stated that this training is now being put in place. The majority of the staff have attended training in relation to autism and supporting one particular person with their challenging behaviour. Further training is planned in October 2007 to ensure that all staff attend training in challenging behaviour. The deputy stated that there have been some issues relating to the lack of instructors for challenging behaviour but this is slowly being addressed. Without a skilled workforce to support the individuals it would be difficult to say that this is a specialist service and this training must be in place with regular updates. Training will be discussed further later in this report. Each person receiving a service had an assessment of need and a personalised contract of care that informed the plan of care. These were commendable. However, the section relating to finances needs reviewing to ensure reflects the new fees and money that the individual is entitled to. Personal Allowances were now out of date and reflected the entitlement two years ago. The Windbound DS0000043699.V349774.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 adequate. This judgement has been made using available evidence including a visit to this service. Individuals support needs are clearly documented. Improvements have been made relating to the safety of others, however concerns are raised about the suitability of the home for one person. EVIDENCE: Care plans gave sufficient detail to enable a clear path of how staff support the individuals. These had been kept under review. It was evident that these were person centred and reflected the preferences of the individual. The home’s care plan linked with the assessment and care plan drawn up by the placing authorities. Reviews were held at regular intervals involving the individual, their relatives, care staff and the placing authority. Key workers complete three monthly reviews, with formal care reviews being organised annually. The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 12 In response to a previous requirement the home has developed a protocol for staff to follow relating to one specific individual when they hit out at staff and people living in the home. The home has actively sought advice from the organisation’s behaviour therapist and South Gloucestershire Council’s Intensive Support Team. In response to an adult safeguarding meeting this person is being supported on a one to one basis to ensure the protection of the people living in the Windbound. This was confirmed in records and in conversations with staff. The deputy manager stated that requests have been made to the placing authority to complete a reassessment of care needs, but as yet no response has been received. The additional one to one staffing is presently being funded by the home, by utilising daily staffing that is already in place. Long term this could have a detrimental effect on the other people living in the home if this is not in addition to the daily staffing numbers. During the safeguarding meetings concerns were raised whether the home was meeting the care needs of the individual. From the conversations with two professionals it was evident that the environment was a contributing factor towards the challenging behaviour exhibited and it was felt that a smaller care home would be more suitable. Where an individuals needs are not being met the home should consider whether notice should be given to end the placement. Risk assessments were in place and covered a wide spectrum of activities both in the home and the community. Support plans included information on how the individual should be supported with their challenging behaviour including the triggers. These have recently been reviewed. Training is being organised for staff in October 2007 on the principles of supporting individuals with challenging behaviour. Records were being maintained in the event that staff have to use restraint. Staff confirmed that this is used as a last result. Staff will receive refresher training in October on the restraint techniques that can be used in the home. The home has responded to a recommendation to review the terminology in respect of one individual which now states “small person hold”. The Windbound DS0000043699.V349774.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): 12,13,15,16,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst there has been some improvement in relation to the structure of activities, these could benefit from a review to ensure that the home has capacity to enable all the activities to take place. Individuals are encouraged to maintain contact with relatives. Individuals have a healthy and varied diet available to them. EVIDENCE: From evidence gathered during the visit in April 2007 there were concerns raised about the lack of structure for individuals in relation to activities that are offered. It would appear that those that “shouted louder” were supported to go out on trips and activities that were offered did not link to the individual’s needs or aspirations. In response the home has developed a structured activity plan for each person. This was reviewed on this occasion. The plans would appear unrealistic with no reflection on staffing and how the activities The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 14 organised would impact on the individuals. From conversations with the staff it was evident that it is not realistic for them to complete. The home must review the activities to ensure that they have capacity to complete them. Staff stated that whilst they would like to do all that was on the plans quite often they felt they had failed due to the lack of manpower. For example on one particular day going through all the plans they would have to be in excess of nine staff to enable the swimming, arts and crafts and a trip to the local shops to happen. Staff stated that in addition to the activities, staff are expected to complete household chores and catering tasks. It would appear from looking at the plans that the home has gone from one extreme to the other. Another concern is that some of the individuals may benefit from less structure and some free time to relax. The daily records did evidence that some of the activities were taking place and how the individual had enjoyed the session, in addition to where individuals had refused to participate. However, one individual’s plan was not reflected in the daily record and in fact the person had evidently had benefited from increased trips out in the minibus on some occasions going out three times during the day irrespective of what their behaviour was like. There is a risk that this could be seen as a reward for negative behaviour. Individuals are supported to attend college, swimming, arts and crafts, trips out, relaxation and visits to church. Annual holidays are arranged for those individuals that benefit. For some of the individuals a holiday would not be beneficial due to the way the individuals react to change however from conversations with staff and the deputy manager this is constantly kept under review. One individual has recently been supported by two staff for a weekend break and this was seen as a positive step for the individual. Other individuals have been supported to go for breaks by the sea and one individual went to Euro Disney. It was evident from conversations that the holidays were tailored to the individual. Individuals living in the home confirmed that they have contact with relatives. Staff stated that individuals are supported to visit relatives in their home. Some of the individuals use the telephone to maintain contact. This is commended, as some relatives are not local. This was further evidenced in care records. Individuals have available to them a nutritious and varied diet. In addition to the planned menu there is a list of alternatives. A record of meals is recorded for each individual in the daily diaries. This is good practice. Staff described how the individuals in flat one are encouraged to take more of an active role in the preparation of food including shopping. Individuals confirmed at the last visit that the food was good. There were policies and procedures available to staff guiding them on the safe handling of food. Records for fridge/freezer temperatures were consistently being completed. Cupboards were well stocked with a combination of fresh and convenience food. The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 15 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. Personal and health care needs were being met. There is good access to other agencies in supporting the individuals. EVIDENCE: Records demonstrated that individual’s health and personal care needs were being met. The home has good links with the community learning disability team and individuals are referred as their needs change. Individuals have access to a GP, dentist and an optician. The home’s statement of purpose clarifies which therapeutic techniques are on offer at the Windbound. These include access to the community learning disability team, consultant psychiatry and psychology. In addition there is a counselling service, chiropody, hairdressing and therapeutic massage. From reading the record of visitors the home is actively supporting one of the individuals with a recent bereavement and is accessing support from a specialist counselling service. This is good practice. The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 16 The home has recently purchased specialist equipment for a relaxation room for the use of the people living at the Windbound. The staff were evidently pleased with the effect this was having on the individuals living in the home. Medication was not reviewed on this occasion. Previous visits have demonstrated that there are robust systems in place to ensure that the individuals medication is administered safety and within the home’s policies and guidelines. The deputy manager stated that all staff have recently attended medication training. The home was waiting for the certificates. Good quality initiatives were taking place to the ensure the administration of medication was appropriate and in accordance with the local procedures. The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that their concerns would be listened to. However, there are concerns on how the home responds to safeguarding issues and the reporting to the local authority. EVIDENCE: The home has a complaints procedure this is clearly displayed in the entrance to the home along with the most recent inspection report. The home has not had a complaint in the last twelve months. Staff on previous visits have demonstrated a good awareness of the complaints process. The home has recently been subject to an adult safeguarding procedure. Two meetings were held with South Gloucestershire Council to determine the safety of the individuals living in the Windbound in respect of one person attacking both people receiving a care service and staff. The home has provided one to one staffing for the individual and devised a clear support plan in relation to the behaviours that challenge. The home is keeping the Commission for Social Care Inspection informed of all incidents of aggression towards the individuals living in the home. It is strongly advised that copies of these reports are sent to the placing authority and a referral made for an urgent review as previously discussed in this report. During the visit to the home in April it was strongly recommended that the home instigate the adult safeguarding procedures in relation to the above. The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 18 There was a significant delay. The manager and the deputy manager stated that there had been reluctance from the previous area manager. The home must ensure that all safeguarding issues are discussed with the local authority and for them to decide the best course of action in relation to the investigation. The deputy manager stated that the home has purchased a new training package, which includes safeguarding adults training. At the last inspection it was noted that the attendance record for Protection from Abuse Training showed that not all staff, including the manager and the deputy had attended. Reassurances were given by the deputy that a training plan has been developed which includes the manager attending an appropriate course for managers on safeguarding issues. The South Gloucestershire Council’s safeguarding adult’s co-ordinator will be arranging a meeting to discuss the principles of “No Secrets” and the local authority’s policy as part of the strategy meeting. This will be followed up in relation to training for staff at the next inspection. During the visit in June 2007 it was noted that all staff have been given copies of the adult protection policy and whistle blowing policy. In response to a requirement from the visit in June 2007 all staff have been given a copy of the General Social Care Council’s Code of conduct. This was confirmed in conversations with staff and a record of staff signatures confirming they have had a copy. Finances were not inspected on this occasion. Regulation 26 visits by the provider randomly checks finances on a monthly basis. Care plans were in place detailing the support needs for individuals who use the service in relation to their finances. Although as mentioned earlier in this report these require updating to reflect the correct personal allowance entitlements. The Windbound DS0000043699.V349774.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 adequate. This judgement has been made using available evidence including a visit to this service. People living in the Windbound are benefiting from a refurbishment plan that is ongoing. The Windbound was clean and free from odour. EVIDENCE: The Windbound is a split-level property with the residential provision on the upper level. Accommodation for people who use the service is provided in four flats. The manager’s office, training rooms and a relaxation room are on the ground floor. In addition there are a number of offices, which in the past have been used by the operations and the training manager for Voyage. The four flats have access to a lounge and three of the flats share a communal kitchen, which is domestic in scale, and there are separate bathroom facilities. The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 20 As discussed earlier in this report there are plans to make some changes to the building to make the flats more self-contained. The deputy manager stated that the organisation is exploring how the home can utilise some of the space on the ground floor. This will include an activity space for arts and crafts/day care activities and a meeting room for families and friends, which will afford the people who use the service more privacy. Since the last visit the staff have developed a relaxation area in the manager’s previous office. It was evident that this has been to the benefit of the individuals who live at the Windbound. The home was undergoing some works during the visit, which included new flooring to some of the lounges and the kitchens. One of the flats has had soft carpeting put throughout. This has enhanced the homely feel to this area. One person stated that it was much better. The home has responded to a requirement to replace the guttering and facia boards. In addition further maintenance work is planned to include decoration, whilst no requirement has been made in relation to the environment this ongoing programme of works is needed to ensure that the Windbound is a pleasant place to live. The home was found to be clean and free from odour. Response to repairs was good with a general maintenance person visiting the home regularly. The home has a number of outbuildings, which house the laundry, food store and potting shed. The deputy stated that the gardens are being developed and the plan is for the gardens to be more useable by the people living in the Windbound. The Windbound DS0000043699.V349774.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): 32,34,35,36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been significant improvements to staff training and support. These must continue to ensure that staff have the competence, the direction and the support to provide the care to the individuals living at the Windbound. EVIDENCE: Evidence was provided that the home was adequately staffed in accordance with the assessed care needs and the statement of purpose. However, the staff stated that there have been some incidences when there has only been the minimum staff supporting the individuals. It was noted that on one day there were 10 staff supporting the individuals and another day there were six. A member of staff stated that there has been some difficulties covering the shifts as staff have been on annual leave and there has been some sickness. The manager has developed a protocol for the taking of annual leave to reduce the stress on the planning of the rota and was in the process of employing additional staff. Staff, during the inspection, described a good cohesive team and good support mechanisms in place. In response to a previous requirement there are now The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 22 regular team meetings and one to one support for staff. This was evidenced via the team meeting minutes and records of supervisions. Recruitment records were viewed as copies have been obtained for newly appointed staff. Evidence was provided that a thorough recruitment process had been undertaken and satisfactory checks had been completed. The organisation had policies on equal opportunities and recruitment processes as seen at a previous inspection. A member of staff confirmed that they had completed their induction and that their mentor had been very supportive in offering the direction and guidance. Records were seen confirming that the induction process had been completed in a timely manner as per the National Minimum Standards. The deputy manager stated that the organisation is reviewing the induction standards and the plan was to introduce the Learning Disability Award Framework. This will be reviewed at the next visit to the home. All staff had a good awareness of their roles and the care needs of the individuals living in the home. In response to a previous requirement the home has developed a training plan, which has included training in health and safety, food hygiene, manual handling and first aid. Those staff that needed this training completed this in August. The home was waiting for the certificates. As already discussed in this report there have been some issues ensuring that staff are trained in supporting individuals that challenge and autism. The deputy manager stated training for supporting individuals that challenge is being completed in October 2007 and some training has already been offered to staff on autism. This will be followed up at the next visit to the home. It was evident from documentation, talking with staff and the deputy that the home was working towards the target of ensuring that 50 of the workforce have a National Vocational Award. The home has external assessors to support staff undertaking their NVQ. The Windbound DS0000043699.V349774.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 adequate. This judgement has been made using available evidence including a visit to this service. There has been improvement in the management of the home; there is an open door approach with good support for the staff working in the home. However, there is no registered manager and this has been an ongoing concern. EVIDENCE: Ms Richings has recently withdrawn her application to become the registered manager to enable her to gain more skills and knowledge in relation to the National Minimum Standards. Ms Richings is presently undertaking a management course with the organisation and will proceed to complete a National Vocational Award level 4 in management and care. The Commission for Social Care Inspection has supported this decision however; there is an expectation that the application will be submitted by the 24th October 2007. The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 24 Staff spoke very highly about the support offered by the manager of the home. It was evident that the manager offered an “open door” style of management. There are concerns that the Windbound has not had a registered manager since May 2006. In addition four operational managers have supported the home in the last twelve months. Letters have been written to the director of operations relating to both the senior management and the legal requirement to have a registered manager in post. Reassurances have been given and this will continue to be monitored by the Commission for Social Care Inspection. The Commission for Social Care Inspection has received regular reports of monitoring visits in respect of regulation 26 conducted by the operations manager. In addition comprehensive monitoring “Monthly Service Review Programmes” are carried out following the Voyage organisations own selfmontiting quality assurance system. Questionnaires are sent to relatives, professionals and individuals receiving a care service on an annual basis. Records were held securely and generally found to be in a logical and accessible format. Policies and procedures were not viewed on this occasion. There were good systems in place to ensure the safety of people living in the Windbound and the staff team. Information was accessible to staff and included policies and procedures and risk assessments. Routine checks on the premises were being completed including the testing of the electrical appliances, servicing of the gas appliances and routine checks on the fire equipment. These systems also included checks on wheel chairs and the home’s vehicles. Logs were maintained of the checks. This is good practice. A comprehensive folder contained all the data sheets in respect of chemicals used in the home. The deputy manager stated that this particular area has been allocated to a member of staff working in the home to review to ensure information is up to date. The majority of the staff have been allocated a specific task or area of responsibility. The manager and the organisation submitted an improvement plan that states how the home will ensure compliance to the legislation and the requirements from the visit in April 2007. It was evident that there was a commitment to addressing the home’s shortfalls making the Windbound a better place to live and work. The manager and the operations manager that was in post at the time attended a meeting with the Commission for Social Care Inspection to discuss the improvement plan. It was evident from both this and the visit in June 2007 that much work has been undertaken in relation to the improvement plan and the requirements from the previous visits have been met. However, this must continue and become part of the culture of the home and will continue to be a focus on subsequent visits. The Windbound DS0000043699.V349774.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 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 3 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 1 X 3 X X 3 X The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 26 No 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 YA5 Regulation 5A Requirement To review the licence agreements and care plans re finances to ensure reflects current fees and what the individual is entitled to in relation to personal allowances. For the individuals to have clear plans of care around their communication needs. For one individual to be referred for reassessment with placing authority to ensure the home is meeting their assessed care needs. To review activity plans for individuals to ensure that they are realistic and that sufficient staff are on duty to enable the activities to take place. The home must ensure that they liaise with the local council in respect of safeguarding adult issues. To continue with the training of staff including challenging behaviour, mental health, safeguarding (POVA) and epilepsy. The manager must submit an application for registration to the DS0000043699.V349774.R01.S.doc Timescale for action 25/11/07 2. 3. YA6 YA6 15 (1) 14 (2) (b) 25/11/07 25/10/07 4. YA12 16 (2) 25/10/07 5. YA23 13 (6) 25/09/07 6. YA35 18 (1) (c) 25/11/07 6. YA37 Care Standards 24/10/07 The Windbound Version 5.2 Page 27 Act - to the Commission for Social Care Inspection. 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 YA35 Good Practice Recommendations For new staff to complete the Learning Disability Award Framework as per standard 35 (Outstanding) The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 The Windbound DS0000043699.V349774.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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