Inspection on 13/12/05 for Windermere Rest Home

This inspection was carried out on 13th December 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Windermere Rest Home 09/04/09

Windermere Rest Home 09/04/08

Windermere Rest Home 18/04/07

Windermere Rest Home 05/10/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Windermere Rest Home Windermere Rest Home 23/25 Windermere Road Southend-on-Sea Essex SS1 2RF Lead Inspector Christine Bennett Unannounced Inspection 13th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Windermere Rest Home Address Windermere Rest Home 23/25 Windermere Road Southend-on-Sea Essex SS1 2RF 01702 303647 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) Mr Kumarasingham Dharmasingham & Mrs Mithila Dharmasingham Ms Diane Elizabeth Kimber Care Home 10 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (10) of places Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Mr and Mrs Dharmasingham have agreed POVA training within nine months of registration. Mr and Mrs Dharmasingham have agreed Health and Safety training within one year of registration. Ms Kimber (Manager) undertakes POVA training within three months of registration. Thermosatic controlled values on all hot water taps accessible to residents. This work to be carried out within six months of registration. Radiator covers to be provided to all remaining radiators. This work to be carried out within one year of registration. To provide locks on all bedroom doors enabling access from outside to comply with fire regulations.This work to be carried out within nine months of registration, with Risk Assessment and Fire Department approval of them in the meantime. Date of last inspection Brief Description of the Service: Windermere Rest Home is a small, privately owned residential home providing accommodation and care for ten people who may have dementia. Accommodation consists of ten single bedrooms, a communal lounge/dining room, kitchen, two bathrooms, laundry and office. Each bedroom has a call bell facility and a TV point. A shaft lift is available to provide access to both floors. There is a small, enclosed garden to the rear of the home. The home is situated in a residential area of Southend on Sea within easy access of the seafront, train links, bus services and local shops. The home provides display permits to allow visitors to use a private car park opposite the home. Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on 14th December 2005, over 8 hours 15 minutes. It was the first inspection since the home was re-registered with a new provider in October 2005 and was done to monitor the requirements of registration. The inspection process included discussions with the manager, deputy manager, one member of staff, a visiting district nurse, 6 visitors, 3 residents who were able to give their views and observation of the remaining residents. A tour of the premises was undertaken and records were sampled. What the service does well: What has improved since the last inspection? Although the home has been running for a long time, it became registered with a new owner in October 2005, therefore this is not applicable. Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 & 6 The home’s Statement of Purpose and Service User Guide are not adequate and freely available to provide prospective residents with the information they need to make an informed choice. The pre admission assessment and reviews could be developed to ensure appropriate admissions to the home. EVIDENCE: The registered provider has owned the home since October 2005 and has provided CSCI with a Statement of Purpose and Service User Guide. However this does not provide enough information for prospective service users to be clear about the services the home provides to meet their needs. During the inspection an advocate for a prospective service user came to view the home and asked for a service user guide. Unfortunately the only one available was one relating to the previous owner with out of date information. The manager described a thorough pre admission assessment, which gave the resident and their relative the opportunity to visit the home and spend time with the other residents before making a decision. The pre admission assessment form used by the home should be developed to include detailed information about the care needs of the person and how they will be met. Reviews are held approximately one month after admission for residents referred by social services. Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 9 However the home has no review process for private residents. It is good practice to have a formal review after admission, and at regular periods thereafter, involving residents, relatives and any other agencies to ensure that care needs are being met. The home does not provide intermediate care. Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7&8 Care plans do not have enough information recorded, which could mean that care needs are not met. Health needs are met with good input from multi disciplinary agencies but this is not evidenced in records. EVIDENCE: The care plan of one resident was examined. Information was not clearly recorded and the care needs, risk assessments and risk management were either not recorded, or not recorded in a way to make it easy to understand. Care staff at the home had a very good knowledge of the residents and their likes and dislikes and the quality of care seen and substantiated by residents and relatives, was not evidenced in the documentation. However daily records were detailed and gave a good picture of how a resident had spent their day. Relatives comments were, “the home is very good, no complaints whatsoever”, “it’s homely, a personal touch”, and “the staff seem very friendly and approachable – they genuinely care for the residents – they seem very fond of my mother”. The district nurse was visiting the home during the inspection and said, “I don’t have any problems with this place, the staff always come with you to patients.” The manager also spoke of visits to the home by the optician, GP, chiropodist and hearing aid dept. and these visits must be documented in the care plan of each individual resident. Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 13 Some social activities take place but should be developed to occupy residents’ time. EVIDENCE: The manager has recently attended a training course on activities. Due to the frailty of a number of residents, most of the activity is provided on an individual basis, although the manager said that they had enjoyed the carol singers from the local church the previous evening. One resident does jigsaws with the help of a carer and one staff member did skipping as part of reminiscence, which got the residents talking about their youth and the things they used to do. There was generally lots of chatting and laughing and the home had a pleasant atmosphere. One lady goes to an outside club twice a week and another lady goes to a club weekly. Visitors are able to come to the home at any time, and this was evidenced at inspection, when six visitors were seen by the inspector. The occupation of the residents needs to be developed further to ensure the residents receive a stimulating and varied life in the home. Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The complaints policy and the policy relating to abuse need updating. This shortfall could potentially leave the residents at risk. EVIDENCE: There have been no complaints since the last inspection and relatives felt that any complaint would be acted upon by the manager. However the policy and procedure needs to clarify that a complaint can be made directly to CSCI and the procedure should be clearly displayed with contact details of the local office. A complaints book must also be available to record any complaints and the outcome. There have been no Protection of Vulnerable Adults (POVA) incidents at the home. One member of staff is a trainer for POVA but the manager and the staff have not completed their POVA training. The manager was unclear about the procedures relating to reporting an incident and must complete the training in line with the condition of registration, in order to protect the residents in the home. The registered persons must also submit evidence to CSCI when they have complied with the condition of registration in this respect. The policy relating to POVA needs to be updated. Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 The home is clean and odour free and creates a comfortable environment for residents. Compliance with the regulatory bodies will ensure the safety of the residents. EVIDENCE: The upstairs windows now have a safe method of restricted opening, and risk assessments are in place. Some radiators have been covered and the remaining ones must have risk assessments in place until this task has been completed. Records must be kept weekly regarding the running of taps and the recording of temperatures at which the hot water is being delivered (to prevent contamination with legionella). The cupboard under the stairs has been cleared of toilet rolls and flammable materials, but the home has been advised to consult with the fire brigade in relation to the suitability of the locks on resident’s doors. No resident at present holds a key to their bedroom door. The home must consult with the environmental health agency for advice on infection control in the laundry area. The home is clean and there are no offensive odours and it provides a homely atmosphere for the residents. Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Staff numbers need to be increased to allow the manager to fulfil her managerial role. Recruitment practice must be tightened up to protect the residents from risk. EVIDENCE: The home has not replaced the hours worked by the previous manager and as a result the current manager is working a shift pattern as a carer, which does not allow her to fulfil her managerial role. The home has not had any new staff but is in the process of recruiting. Records were seen for one of the applicants. A ten year previous employment record had not been recorded and although the applicant’s previous employment had been a care placement, references offered were personal, and not from a past employer. It was also not clear if the applicant had the right to work in this country. The home must have a thorough recruitment practice in place to protect the residents. Staff have not been issued with a contract detailing the terms and conditions of employment, a job description or a copy of the GSCC code of conduct and practice. The manager has an NVQ level 4 qualifications in care and management. Two members of staff have a NVQ level 3 qualifications and are commencing level 4 in January 2006, and another two members of staff have NVQ level 2. Staff should have an individual training and development assessment and profile. Manual handling training and POVA training must be updated for staff. Three staff have attended Dementia training. Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 & 35 The manager has a good understanding of the areas in which the home needs to improve to benefit the staff and the residents of the home. EVIDENCE: The manager has worked at the home for fourteen years and has achieved NVQ level 4 in care and management, and gave evidence of additional training she has undertaken to update her skills. She has been in post as manager since October 2005 and must acquire a job description to enable her to take responsibility for fulfilling her role, and have a clear line of accountability within the home and with the registered provider. The manager has recently started to have formal residents meetings as part of a quality assurance programme. This needs to be developed to include the views of relatives, staff and stakeholders in the community and an action plan produced annually. Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 16 The policies and procedures of the home must be reviewed to reflect current practice and monthly reports relating to Regulation 26 be submitted to CSCI. The home encourages the residents to handle their own finances. Money held by the home for individual residents was checked and found to be correct but must be recorded appropriately. Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 X X X X X 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X X Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 18 N/A 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 OP1 Regulation 4 (1) Requirement The registered person must produce a Statement of Purpose and a Service User Guide which meets the requirements of thus regulation and submit it to CSCI. The registered person must prepare a written plan with consultation with the resident/ relative as to how needs will be met. This particularly applies to risk assessments and their management. The registered person must maintain a record of complaints about the operation of the home and the action taken. There must be a clear complaints procedure which conforms to all the requirements of Regulation 22 The registered person must make arrangements to prevent residents from being abused. This refers to the policies and procedures being in place and known to staff and training being provided The registered person must ensure the premises promote the DS0000065465.V271779.R01.S.doc Timescale for action 01/03/06 2 OP7 15 01/04/06 3 OP16 22 Sch (4) 01/04/06 4 OP18 13(6) 01/03/06 5 OP19 23(2) 01/07/06 Windermere Rest Home Version 5.0 Page 19 6 OP25 13(4)(a) health and welfare of the residents. This refers to areas identified at registration i.e. kitchen cupboards and work surfaces. The registered person must ensure that all parts of the home are as far as reasonably practicable free from hazards and that unnecessary risks to residents are identified and as far as possible eliminated. Hazards and risks identified are: The regulating and recording of water temperatures. Some radiators need covers. The registered person must make arrangements to prevent the spread of infection and ensure satisfactory standards of hygiene. This refers to the laundry area The registered person must ensure that at all times there are suitably qualified, competent and experienced persons working at the home in such number as are appropriate for the health and welfare of the residents. The registered person must operate a sound recruitment programme as detailed in Schedule 2 The registered person must ensure that staff receive training appropriate to the work that they perform. The registered person must maintain a quality assurance system for reviewing and improving the quality of care provided. The registered person must prepare a written report on the conduct of the home and supply a copy to the CSCI monthly. DS0000065465.V271779.R01.S.doc 01/07/06 7 OP26 13(3) 16(2) 01/04/06 8 OP27 18(1) a 01/03/06 9 OP29 17(3) b 01/03/06 10 OP30 18(1) c (1) 24, 26 01/04/06 11 OP33 01/03/06 Windermere Rest Home Version 5.0 Page 20 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 OP3 Good Practice Recommendations The registered person is recommended to develop the pre admission assessment form to identify care needs and how they will be met, and arrange a formal review for all residents approximately one month after admission. The registered person is recommended to make a budget available to provide a programme of activities and provide facilities for recreation. It is recommended that the manager’s role is defined and time provided for her to fulfil her managerial duties. 2 3 OP12 OP31 Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Windermere Rest Home DS0000065465.V271779.R01.S.doc Version 5.0 Page 22 - 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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