Inspection on 26/04/06 for The Windbound

This inspection was carried out on 26th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 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 25/09/07

The Windbound 03/04/07

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 Nr Thornbury South Glos BS35 1RW Lead Inspector Paula Cordell Key Inspection 26th April 2006 09:30 The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 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.V290885.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 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.V290885.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Windbound Address Shepperdine Nr Thornbury South Glos 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 Mrs Vicky-Sue Hewer Care Home 12 Category(ies) of Learning disability (12) registration, with number of places The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 2006 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. The home is being temporary managed by the deputy in the manager’s absence. The fees for the home at the time of publishing this report range from £1,092 to £2,779 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.V290885.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection. The purpose of the visit was to monitor the progress to the requirements and recommendations from the last announced inspection in January 2006 and review the standard of care provided to the residents at the Windbound. The newly appointed deputy manager was present during the inspection, who was acting manager due to the registered manager’s period of absence. In addition the inspector had an opportunity to speak with the operations manager and the training manager. The focus of the inspection was on the general care of a sample group of residents and the environment, including an extensive tour of the premises. This provided a good opportunity to observe residents in the different flats as well as allowing for informal conversations with individuals and the staff supporting them. Three members of staff were spoken with during the inspection, including the deputy manager. The provider has been sending reports of the monthly regulation 26 visits and these were used to plan the inspection along with the pre-inspection questionnaire. The inspection was conducted over a period of 6.5 hours. Throughout the inspection staff and the deputy were found to be courteous and helpful in the inspection process. What the service does well: Resident’s benefit from clear person centred plans of care enabling staff to support them consistently with their identified care needs. The home’s preferred system of de-escalating aggressive behaviours (CALM) including methods of deflection and physical intervention is of a high quality. Recording or strategies and agreed responses are of a quality as is the recording and the monitoring of incidents and indeed the continual training programme for staff. The home has started on a program of maintenance and renewal of furnishings, fittings and fixtures. The quality and the replacement of the kitchens recently refurbished are of an encouragingly good quality. The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 6 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. What has improved since the last inspection? What they could do better: There is one outstanding requirement and one recommendation relating to the area of staff management, which includes the supervision of staff, and meetings which would increase the support for staff and further ensure consistency and give staff a forum to air their views on the care provided at the Windbound. This has been extended to enable the home to demonstrate compliance. The other outstanding requirement relates to the registered manager completing the NVQ 4 in care and management and the registered manager’s award. This is still within the timescale. There are a number of requirements and recommendations from this inspection covering the range of standards of the National Minimum Standards The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 7 to ensure that a quality and safe service is provided to the residents living at the Windbound. Residents would be assured their safety if the home followed good practice guidelines in the storage of food. Residents would benefit from a staff group receiving regular and frequent supervisions and regular staff meetings. One of the residents would benefit from having some form of window coverage to ensure their privacy as their room is overlooked from a public footpath. Residents would benefit if their care documentation was signed and dated to demonstrate that this was kept under review. In addition their individual risk assessments must be kept under review. Residents must be assured that a thorough recruitment process is instigated ensuring their protection. Residents would benefit from a record of complaint being maintained and be readily available. Residents and staff would benefit if the home had a plan to ensure that government targets in training were being met including NVQ and the learning disability award. However, this should not distract from the comprehensive training package that is already in place but enhance the skills of the workforce. Residents would be assured their safety in the event of a fire if staff received appropriate instructions in fire drills and periodic training in addition to the annual training provided. Individuals receiving a care service in all settings would benefit if an individual who has recently been dismissed were referred to the Department of Health’s Protection of Vulnerable adults Register for consideration. 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 Windbound DS0000043699.V290885.R01.S.doc Version 5.1 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.V290885.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ benefit from clear information about the service provided at the Windbound, which is tailored, to the individual. There are robust admission processes demonstrating that individuals care needs are assessed. EVIDENCE: The statement of purpose was read prior to the inspection. This was found to contain all the information as required by the National Minimum Standards and the Care Home’s Regulations. This has been reviewed by Voyage to ensure that this is specific to the care needs of the individuals living at the Windbound. The statement of purpose includes information about the keypad system, which is used to separate the three flats. The Commission for Social Care Inspection had raised concerns that this was used to the detriment of the residents and constituted a breach of individual resident’s rights. There was clear documentation to support the reasons for the keypads both in individual risk assessments, the statement of purpose and this was kept under review. On the day of the inspection it was observed that all areas of the home were accessible and residents could freely move around the home and a secure garden area. Discussions with staff confirmed this observation who stated that The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 10 the keypads are only activated at night or in accordance with the risk assessment. Each service user had an assessment of need and a personalised contract of care that informed the plan of care. These were commendable. There was good evidence that the home’s care staff had the capacity and the skills to meet and deliver the services, which the home offers to provide. The statement of purpose clearly describes the admission process and the criteria for potential individuals that the home could support. The home has an established group of residents with no vacancies. However, the home must ensure that the home could meet the needs of any new resident ensuring that this does not compromise the care of individuals already placed and that the staff have capacity and the skills to support the new individual. For the foreseeable future this will need to be reappraised at forthcoming inspections. The inspector was pleased to see that where an individual was planning to move to another home photographs had been taken both of the new home and the staff team. It was evident that these were being used to aid the transition. If this process were transferred to new residents who were potentially moving to the Windbound this would only enhance the information in place. The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 the service. Residents can be assured that the care planning process was robust and clearly described their individual care needs. Systems for the involvement of relatives and professionals were in place. Limitations to choice or human rights was documented clearly in plans of care and reviewed appropriately. However, risk assessments and care documentation must be kept under review. EVIDENCE: Care planning in the home is of a consistently high quality. There was evidence of six monthly care reviews completed by the staff and an annual review. The latter was clear that it involved the service user, other professionals and relatives where relevant. A resident confirmed their involvement in the care review stating that a meeting was planned within the next week. Four residents spoken with stated that they liked living at the Windbound, although one individual stated they would prefer to live with family and another wanted to change their room to the lower floor. Residents were observed moving freely around their individual flats and accessing the secure The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 12 garden over looking the river Severn. One of the residents spent the majority of the day on the ground floor doing chores and working in the garden. It was evident that this was a responsibility the person cherished and valued. Care plans were person centred with a number of staff having been trained in this approach. Discussions with staff demonstrated that they had a good understanding of person centred care, user participation and the rights of the individuals living in the home. Records further evidenced how individuals are supported to make choices and communicate their care needs. A number of staff have attended a course on sign language specific to individuals with a learning disability. This was observed in use during the inspection. The inspector was given a box of photographs to assist with communicating with an individual this was commendable and greatly assisted in the inspection process and seeking the views of the individual. It was noted that some care documentation lacked a date and a staff signature. An opportunity was taken to view the records for three residents. Two of the three residents’ risk assessments had been reviewed at three monthly intervals whilst the third had not been reviewed since June 2004. Risk assessments included information on restrictions imposed on individuals and the reasons. For one individual it was clear that this had been discussed with the placing authority, relatives and other professionals. It was evident that the deputy and the staff were committed to the care of the residents and were substantially reviewing strategies and approaches to the individual ensuring it remained appropriate. Behaviour strategies were in place detailing the triggers, de-escalating strategies and the interventions. These were personalised to the individual. There were clear records of incidents of behaviour and the strategies used. Staff confirmed the home’s policy that restraint was only used as a last result and that the home uses techniques that cause no physical discomfort. Staff records confirmed training is annual. Discussions with two staff confirmed that they had received this within the first week of employment. This is good practice. There was evidence that other professionals are involved in the planning of the care with regular reviews from placing authorities and the community learning disability team. Consultation with residents whilst not formal was evident on a day-to-day basis in the planning of their care and more formally at the key worker meetings and the individual’s care review. However, the key worker reviews were adhoc one resident had two care reviews, whilst another had only had one and the third none. A recommendation would be to formalise this to ensure that they consistently take place to ensure that there is a regular forum for residents to air their views. The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 13 The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ social, emotional and communication needs were being addressed. Residents have opportunities to participate in activities both in the home and the community. Residents are offered a varied and nutritious diet. EVIDENCE: Care plans included information on how the home was meeting individual’s social, emotional, communication and personal development needs. This was further confirmed in the daily record for individuals and in discussions with staff and residents. The deputy stated that whilst there are structured programmes of activities this is not fixed in stone and depends on the preferences of the individual and the individual’s stability in relation to the behaviours that challenge. A member of staff confirmed that residents have opportunities to go out on a daily basis and two drivers work in the home per shift to enable this to happen. It was emphasised by all staff that there is a commitment to ensure that residents The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 15 have a balance of relaxation time and structured activities tailored to the individual. The home is fairly remote however access to the local community was maintained. There was information recorded in the daily records that confirmed that the residents regularly go out on a range of trips to the local community. Good and comprehensive risk assessments were in place to demonstrate that the staffing was adequate to meet the needs of the residents and assure the safety of all concerned. The home has vehicles for residents use. On the day of the inspection a group of residents were going shopping whilst another group were going swimming and out for lunch. Records demonstrated that residents were supported to go to the cinema, out for meals and other places of interest. One resident made reference using non-verbal communication that they wished to go out by fetching their shoes and pointing. Not long after these comments were witnessed that it was seen that they were going out for a walk along the lane accompanied by a member of staff. Another resident during the inspection was seen sitting with staff using picture cards to assist with communication. This is good practice and demonstrated that staff listened and acted on what residents were saying and were exploring alternatives to ensure residents could communicate effectively. A number of staff had received training in sign language. This was observed during the inspection in use with some of the residents. Concerns had been raised about one individual living in isolation of the others due to behaviour. However from conversations with staff and the individual it was evident that they were being supported and encouraged to interact with both residents, staff and accessing the community. This was further evidenced in care planning documentation and daily records. Staff and residents were keen to share their planned holiday experiences. From these conversations it was evident that holidays were being tailored to the individual. Care records included information about contact with relatives. Views of relatives were sought during the reviews and evidently were kept informed of changes to the individuals’ plan of care. Photographs evidenced that relatives and friends were invited to celebrations at the home. One resident confirmed that they could maintain contact with family via the telephone and that they visited relatives and in turn they visited the home. Space is available in the home for residents to entertain their friends and relatives. The home has available to them the ground floor which is set out like a coffee bar and a large room which the inspector was informed was used for arts and crafts. In addition the home has two kitchens and a member of staff stated that one of the kitchens is used to assist with residents gaining skills in food and drink preparation. Whilst the kitchen areas were locked it was evident that The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 16 residents could access these areas with staff supervision and support. As observed during the inspection. Residents have available to them a nutritious and varied diet. In addition to the planned menu there is a list of alternatives. Two residents commented positively on the food provided and that there was a choice available to them if they did not like what was on offer. Food cupboards were well stocked with a combination of fresh and convenience food. Concerns were raised during this inspection that food, which had been opened in the fridge, was not labelled and dated. There were policies and procedures available to staff guiding them on the safe handling of food. Records for fridge/freezer and food temperatures were consistently being completed. The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20,21 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ personal and health care needs were being met. Residents’ can be assured that there is a robust medication system in the home. Whilst there are policies and procedures to guide staff in the event of a death this would be enhanced if the views of residents were sought on their individual wishes. EVIDENCE: Records were informative about the personal care needs of individuals giving clear direction to staff. This included individual preferences on how they wanted to be supported. Residents are supported to attend appointments with the GP, opticians, dentist and hospital. Residents had very distinctive style in clothes and haircuts. Residents seen on the day of the inspection had the appearance of being well cared for. Evidence was provided that other professionals are consulted on the care provision complimenting the skills and the knowledge of staff. The home operates the key worker system as confirmed in records and conversations with staff and residents. The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 18 The statement of purpose clarifies which therapeutic techniques are on offer at the Windbound. These include access to the Community Learning Disability Team and consultant psychiatry and psychology. In addition there is a counselling service, chiropody, hairdressing and therapeutic massage. Residents have access to a snoozelen room for relaxation. On the day of the inspection some of the residents were attending a hydro pool as part of their therapeutic programme. Medication was satisfactory. The home has developed medication risk assessments and protocols for the use of as and when required medication for each individual involving other professionals and the doctor. This included a homely remedy protocol for each individual. This is good practice. The information was informative and detailed to enable new staff to support individuals. The home has designated staff members who have been assessed as competent that are solely responsible for the administration of medication. Records demonstrated that these staff had attended appropriate training. In addition five staff have been identified to complete a distance learning pack in May 2006 on medication to further enhance their skills and competence. Records relating to stock administration were found to be satisfactory. The home has responded appropriately to a requirement from the last inspection to ensure that medication is stored securely at all times. Evidence was gained from observations and conversations with staff. Quality initiatives were taken place to ensure administration of the medication was appropriate and in accordance with the local procedures. This is good practice. The home has responded to a requirement to ensure that the equipment for the treatment of asthma is now routinely serviced. Guidelines for staff to follow on its use were in place. Training on its use was not seen on this occasion and will be discussed at the next inspection. The home has policies and procedures to support an individual in the event of a terminal illness and death. However, it was not clear whether the views had been sought from residents or their representative on their last wishes in the event of their death. The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Residents can be assured that the home would respond to complaints and issues relating to abuse gained at the last inspection. Robust systems were in place. However, the complaint record was not available for inspection. EVIDENCE: Systems for individuals to raise concerns and complaints were reviewed at the last inspection. Where the home was able to demonstrate that the home would respond to a complaint. Staff interviewed at the last inspection were well informed about the complaint process. This was not reviewed on this occasion. The pre-inspection questionnaire highlighted that the home has received one complaint since the last inspection. However the deputy or the operations manager had no recollection of a complaint and the record of complaints could not be found during this inspection. The home has copies of the local authority’s policy on the protection of vulnerable adults and a copy of No Secrets. The deputy manager and the operations manager could not locate the home’s policy on the protection of vulnerable adults. This was sent to the Commission for Social Care Inspection and clearly demonstrated the process that staff should follow where an allegation of abuse is made. Staff attend a combination of in-house and external courses on abuse. The training manager provides this training and it was suggested that they attend a The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 20 “train the trainer course in abuse” organised by the local authority. It was evident that they were keen to attend to enhance the training. Newly appointed staff stated that they had attended a course on protection of vulnerable adults as part of their induction. This is good practice. The home has instigated the Protection of Vulnerable Adults procedure. The home was fully co-operative and has implemented the recommendations. The home has recently dismissed an individual and according to the operational manager this came under the remit of abuse. However, there was no evidence that the individual had been referred to the POVA register either during their suspension or on their dismissal. The operations manager stated that a senior manager in Voyage makes this decision whether to refer or not. All incidents where staff are suspected or later found must be referred to the Department of Health as per the POVA guidelines. A random selection of individuals’ finances was checked. Whilst no abnormalities were identified – good practice would be that expenditure is supported by two staff signatures in the absence of the individual resident signing. Care plans included information on the support needs for residents in relation to their finances and the contract clearly described what was included in the fees. This is good practice and in accordance with the National Minimum Standards. The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a homely, comfortable and safe environment. Residents right to privacy must be maintained. The home was clean and free from odour. EVIDENCE: Windbound is a split-level property with the residential provision on the upper level. Accommodation for residents is provided in four flats. The manager’s office and training rooms and a café bar is on the ground floor. In addition the operations manager and the training facilitator for Voyage have a suite of offices in an annex accessed separate to the residential care home. 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. Three of the flats were homely and comfortably furnished. Residents’ bedrooms were personalised and contained appropriate furnishings. Flat four in contrast was bare. This was clearly documented in the plan of care and professionals had been consulted. However, one requirement is for the home to ensure that the individual’s privacy is maintained by providing covering to The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 22 their bedroom window as this is overlooked from a public footpath. This should involve consultation with the resident. There are outbuildings that house the laundry, food store and potting shed. The home has responded to a requirement to ensure that these are secure where they contain certain unsafe materials and there is a risk to residents including ensuring that the area containing the gas storage is secure and padlocked. There are a number of outdoor spaces including an enclosed patio area, which can be reached by three of the four flats taking in the views of the river Severn. In addition there is an area that has a large enclosed fishpond and raised beds. There are plans for the home to organise a garden group. There was an ongoing programme of general maintenance and refurbishment of the home. Response to repairs was good with a general maintenance person visiting the home regularly. Minor repairs were being responded to on the day of the inspection. Where the inspector, on the tour of the building had identified areas it was pleasing to note that these had been faxed through to the appropriate person to action. Whilst the home was clean and free from odour, care staff in addition to their caring role, were presently undertaking cleaning duties. The deputy stated that a recruitment initiative has taken place to employ a domestic. Cleaning schedules were seen and this formed part of the staff’s daily records. An architect’s “feasibility drawing” was forwarded to the Commission for Social Care Inspection outlining plans for the wide-ranging refurbishment of the home. This was not discussed during this inspection, as it is understood that no decisions have been arrived at this point in time. The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35,36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Whilst there are sufficient and competent staff supporting the residents, the home has failed to demonstrate that staff receive adequate supervision and support. The training plan is of a good standard however; staff should have an opportunity to complete a National Vocational Award as per the government’s targets, which should enhance the care service provided to the residents ensuring a consistent approach. EVIDENCE: Staff spoken with during this inspection described a good cohesive team and good support mechanisms in place. However, it was evident from supervisions and from conversations that there were mixed feelings on the management support given to them. This will be discussed in the next section of this report. Evidence was provided that the home was adequately staffed in accordance with the assessed care needs and the statement of purpose. The duty rota for the home provided evidence that the home had at least seven staff working in the home during the day and evening and three staff working in the home at night. One of the night staff sleeps in. The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 24 A random selection of staff records were viewed. Whilst the majority of the files were well organised, one member of staff had only one reference this lacked any in-depth information to make a decision whether to employ or not. Concerns were raised with the manager and the operations manager that four recently employed staff files were not available. These were at the main office for Voyage. These must be in the home once staff commence employment in accordance with Care Home’s Regulations. It was difficult to fully determine whether a thorough recruitment process had been undertaken for these four individuals. All staff spoken with had a good awareness of their roles. Contracts and job descriptions were in place. Inductions were seen for new staff and staff confirmed that they had completed a thorough induction and staff were supportive in guiding them during their induction period. New staff in post confirmed that they had completed the crisis and aggression limitation management training (CALM) within the first week of employment. Existing staff confirmed that this was undertaken annually. Training was in place and regularly reviewed to ensure that staff have the skills to enable them to complete their roles. Training was linked to the care needs of the residents. The home has good systems in place to audit the training ensuring that staff attend regular updates in health and safety, first aid, COSHH and annual fire training. In addition staff have attended training specific to individuals with a learning disability including autism, mental health and sign language. A member of staff commended Voyage’s commitment to training. However, it was noted that only two staff had achieved a National Vocational Qualification at level 2. The training manager stated that there are plans to enrol six staff to complete an NVQ 2 and a further five staff to complete an NVQ 3. For the home to meet government targets of 50 of the workforce to have an NVQ - out of the 33 staff at least 17 staff must have an NVQ. It was noted that none of the staff have completed the Learning Disability Award Framework. The training manager stated that this is being discussed and the plan is for all new staff to complete as part of the induction. In spite of a requirement at the last two inspections regular staff supervision is still not available for staff. Voyage has a formal supervision policy and this is not being followed in the home. The deputy stated that she has undertaken supervision with at least half of the staff and a plan is in place to ensure that regular supervision was undertaken. Evidence was seen. This remains a requirement, as this has not fully been met. Whilst there are some valid reasons for this the management team must ensure that the formal supervision process is implemented. There was a mixed message from staff on the communication systems within the home; some said that especially the deputy supported them in the absence of the manager. However, there was a lack of staff meetings these were being held three monthly with the focus being on senior carers. Due to the nature of The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 25 the challenges in the home staff should be supported via the supervision process on an individual level and in team meetings. The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 26 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 Quality in this outcome area is adequate especially relating to the management of the home. This judgement has been made using available evidence including a visit to the service. There are presently issues relating to the management of the home, this is being investigated by Voyage and the deputy is temporarily taking on the responsibility. The home has good systems for the monitoring of the quality and the safety of the home. Resident’s safety in relation to fire is being compromised due to the lack of fire training. EVIDENCE: Mrs Hewer is the registered manager. At the last inspection it was required that the manager complete an NVQ 4 in management by September 2006. This is still within the timescale. The manager is on a period of absence. At the last inspection the staff group were largely divided over the efficiency and competence of the leadership of The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 27 the home. Views and comments from the sample interviewed still echoed these concerns. The operations manager stated that this is being pursued by Voyage. The deputy manager has taken on the responsibility supported by the operations manager to manage the home in the absence of the registered manager. She has worked at the Windbound since 2001 and has completed an NVQ 2 in care and is planning to enrol to complete an NVQ 3 in care. Staff were positive in relation to the support that she has given to staff through a period of low staff morale. The Commission for Social Care Inspection must be kept informed of the management arrangements as discussed during the inspection. The Commission for Social Care Inspection has received regular 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 self-monitoring quality assurance system. It was noted at the last inspection that the review in January 2006 had identified some discrepancies in the home’s budget. Reassurance was given at this inspection that the finances had been retrieved however a full investigation and action was being taken. This process was still being undertaken and an outcome had not been reached. Records were held securely and generally found to be in a logical and accessible format. Voyage has a number of policies and procedures, which have been developed and reviewed over time. They cover all aspects of running a care home and relevant to the individuals that the home supports. Policies and procedures were kept in the main office and in the small office situated on the second floor. These were accessible to staff. Staff confirmed that these were covered during the induction and periodically with them as new policies are introduced. There were good systems in place to ensure the safety of residents and staff. Information was accessible to staff and included policies and procedures, risk assessments. Routine checks on the premises were being completed including the testing of the gas and electrical appliances. These systems also included checks on wheelchairs and the home’s vehicles. Logs were maintained of the checks. This is good practice. An opportunity was taken to view the fire logbook. Whilst it was clear that routine testing was being completed on the fire equipment, information was lacking to demonstrate that staff attend three monthly fire training if working nights and six monthly training if working days and not all staff were attending a fire drill every six months. All staff attended an annual fire-training lecture. The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 28 The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 29 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 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 1 3 3 3 3 2 X The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 30 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA36 YA37 Regulation 18 (2) 9 (2) (i) Requirement The staff team to receive regular support and supervision. (Outstanding from 1/5/06) The registered to complete the National expected qualification (NVQ level 4). (Remains within the time period) To ensure that risk assessments are kept under periodic review as described in the plan of care and the home’s policy. For a record of complaints to be kept in the home For the home to ensure that a resident’s privacy is maintained by providing curtains to their bedroom. This must be undertaken within a risk assessment process and involvement of the resident. Records relating to the recruitment of staff must be held in the home as per schedule 4.6 The home must ensure that a thorough recruitment process takes place including seeking two references for prior to offering employment. Staff to attend regular training in fire as prescribed by the fire DS0000043699.V290885.R01.S.doc Timescale for action 26/06/06 01/09/06 3 YA9 15 (2) (b) 26/05/06 4 5 YA22 YA26 22 Sch. 4.11 16 (2) (c) 26/04/06 07/05/06 6 7 YA34 YA34 17 (2) Sch. 4.6 17 (2) Sch. 4.6 26/04/06 26/04/06 8 YA42 23 (4) (d) 10/05/06 The Windbound Version 5.1 Page 31 9 YA42 23 (4) (e) officer – every three months night staff and six monthly for day staff. For staff to participate in a fire drill once in a six month period. 10/05/06 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 3 4 5 6 7 Refer to Standard YA36 YA36 YA6 YA23 YA35 YA35 YA23 Good Practice Recommendations Staff to receive at least six supervision sessions per annum. Staff meeting to be held regularly at least monthly or as determined by the staff team and the needs of the care home. Care documentation to be dated and signed. For the finance records be supported by two staff signatures and where possible the individual resident. To ensure that 50 of the workforce have an NVQ in care For new staff to complete the Learning Disability Award Framework as per standard 35 For the senior management team to provide evidence that one member of staff who has been dismissed due to issues of abuse be referred to the Department of Health’s POVA register. Where staff are suspended and abuse is sited then staff to be referred to the register as per the Department of Health’s guidance on the register. The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 The Windbound DS0000043699.V290885.R01.S.doc Version 5.1 Page 33 - 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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