CARE HOME ADULTS 18-65
White Windows Cheshire Home Fore Lane Sowerby Bridge West Yorkshire HX6 1BH Lead Inspector
Cheryl Stovin Unannounced Inspection 7th February 2006 12:55 White Windows Cheshire Home DS0000001075.V282345.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 White Windows Cheshire Home DS0000001075.V282345.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. White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service White Windows Cheshire Home Address Fore Lane Sowerby Bridge West Yorkshire HX6 1BH 01422 831981 01422 836645 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) www.leonard-cheshire.org.uk Leonard Cheshire Mrs Carole Davies Care Home 25 Category(ies) of Physical disability (25), Physical disability over registration, with number 65 years of age (25) of places White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 25th August 2005 Brief Description of the Service: White windows is owned and managed by the Leonard Cheshire organisation which is a registered charity. The establishment is registered to provide accommodation and and both personal and nursing care for up to 25 adults with a physical disability. The home is situated in Sowerby Bridge with easy access to the town centre of Halifax. The property, a stone built period residence is well maintained both internally and externally. The home is fully equipped with aids and adaptations to promote the residents independence and all areas are fully accessible. All bedrooms are for single occupancy and highly personalised to reflect the residents interests and tastes. Communal areas are spacious and comfortable and furnished and fitted to a good standard. Externally there are spacious and well maintained gardens and grounds which are fully accessible for wheel chair users. White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 7th February 2006. Over an inspection year from April until March, care homes have a minimum of two inspections a year. The last inspection was also unannounced and took place on 25th August 2005. During the course of this inspection several service users were consulted as to their views of the standard of care and facilities provided within White Windows, and all spoke very highly of the service provided. One resident stated that it was “a superb place to live”, and described how her health had improved since living at the White Windows and is now making plans to return home. What the service does well: What has improved since the last inspection? What they could do better:
Medication administration records must be completed accurately. White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 6 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. White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 7 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 White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 8 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): 1,2,5 Service users are provided with detailed information about the organisation and the services and facilities provided within the home. EVIDENCE: The establishment has recently revised and updated the service user guide which contains detailed information about the organisation and the services and facilities provided within White Windows. The document is produced in an easy to read format. Each resident has an individual contract based on their needs. White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 9 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): 6,7,8,9 Service users needs are thoroughly assessed and the home has a good approach to promoting the service users health care. EVIDENCE: All of the residents contribute to drawing up their individual support plan. The documentation is detailed and holistic and clearly states what support they require and how they wish to be assisted. Attention to detail in the care plans was noted, with evidence of regular review. Residents health care needs are fully assessed and specialist equipment provided, where necessary, to support these. One resident was preparing to move on to independent living as his health has improved whilst living at White Windows. Residents are encouraged to participate in the day to day running of the home and a residents committee is active with regular residents meetings being held which influence the way the home is run. White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 10 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): 11,12,13,14,15,16 Residents are encouraged to exercise choice and care is provided in a flexible manner to enable them to follow their preferred lifestyle. EVIDENCE: Residents preferences regarding daily living activities are identified and flexible packages of support put in place to reflect these. Service users interests are recorded in their plan of care and are given the opportunity and encouragement to follow their interests. A range of activities are provided for the service users to participate in if they choose to do so, the activities on offer are displayed prominently. An activities co-ordinator is employed and works flexibly to ensure that social activities take place during the evenings and weekends. Recent outings have included theatre trips, shopping trips, a barge trip, pub visits and the national railway museum. Several residents also participated with staff in a 10 mile sponsored walk. Visitors are welcome at any reasonable time and are encouraged to be involved with day to day life within the establishment and to join in any social activities. White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 11 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 Residents personal and health care support is given in accordance with their wishes. Care must be taken when completing medication administration records. EVIDENCE: Detailed individual support plans are in place for each resident which clearly indicate their personal support and health care needs and how these are to be met. The establishment uses the Boots MDS (Monitored Dose System) for the administration of medication. The medication is securely and appropriately stored. The qualified nurses are responsible for administering medication in accordance with NMC guidelines, with additional training provided by Boots. Some gaps in medication administration records were identified and care must be taken to ensure that the records are kept accurately. Three residents administer their own medication, which is kept in locked cabinets within their own rooms, with appropriate monitoring systems in place. White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 12 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 Complaints are handled promptly with robust systems in place. EVIDENCE: A complaints procedure is in place, the procedure to follow is detailed in the service user guide. Two complaints have been received and investigated and resolved by the management team. Staff receive training in the protection of vulnerable adults. White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 13 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): 24,25,26,28,29,30 Residents live in a safe, clean and well maintained environment. EVIDENCE: The establishment, a detached stone built period residence, is well maintained both internally and externally. All bedrooms are for single occupancy and highly personalised to reflect their occupants individual tastes and interests. Communal areas are spacious and comfortable and furnished and fitted to a good standard. The home is fully equipped with hoists and tracking and other environmental adaptations to promote the residents independence. Externally, there are well spacious and well maintained gardens and grounds, which are safe and fully accessible to the residents. White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 14 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): 31,32,33,34,35 The home is staffed by a well trained and motivated workforce, with robust recruitment practices in place. EVIDENCE: From records examined and following observation and discussion at the time of the inspection, sufficient staff are deployed to meet the needs of the residents. Staff files examined indicate that an application form is completed, two written references received, and POVA and CRB disclosures are received prior to an offer of employment being made. Residents are involved in the short listing and interview procedures. There is a commitment to training within the establishment, and over 60 of the care staff are qualified to NVQ level II. The organisation gives financial inducements for holding certain qualifications. One newly appointed member of staff was undertaking his induction week programme at the time of the inspection. White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 15 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): 37,38,39,42 The home is well run by an experienced and qualified management team. EVIDENCE: The registered manager of the establishment is qualified and experienced and the management team are committed to ensuring an open and positive atmosphere is prevalent within the home. Service users are encouraged and enabled to contribute to the development of the home and an annual survey of their views is collated and the report of the findings is displayed within the home. Detailed health and safety policies and procedures are in place with regular health and safety meetings held. Training for all staff in safe working practices is mandatory. White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 16 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 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 x 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 3 3 3 x x 3 x White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 17 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 YA20 Regulation 13 Requirement Medication administration records to be completed accurately. Timescale for action 07/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations White Windows Cheshire Home DS0000001075.V282345.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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