Inspection on 25/07/08 for Windmill Care Centre

This inspection was carried out on 25th July 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Windmill Care Centre 21/08/06

Windmill Care Centre 30/08/05

Windmill Care Centre 14/04/05

Windmill Care Centre 18/10/04

Windmill Care Centre 04/05/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

Extracts from inspection reports are licensed from CQC, this page was updated on 09/11/2008.

CARE HOMES FOR OLDER PEOPLE Windmill Care Centre 104 Bath Road Slough Berkshire SL1 3SV Lead Inspector Julie Willis Unannounced Inspection 25th July 2008 10:20 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 DS0000011024.V367760.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000011024.V367760.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windmill Care Centre Address 104 Bath Road Slough Berkshire SL1 3SV 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) 01753 213010 01753 575450 windmill@schealthcare.co.uk www.schealthcare.co.uk Southern Cross (LSC) Ltd Gertrude Mashungupa Care Home 53 Category(ies) of Dementia (23), Old age, not falling within any registration, with number other category (17), Physical disability (13) of places DS0000011024.V367760.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That Service User Categories DE and OP over the age of 60 can be accommodated. 21st August 2006 Date of last inspection Brief Description of the Service: This purpose-built Nursing Home for 53 residents caters for people with frailty associated with older age including mental frailty. It also caters for younger people with physical disabilities. The accommodation is arranged over three floors with separate facilities on each level including lounges, dining rooms and kitchenettes. There are two lifts that service the floors and basement. The catering, laundry, hairdressing and sensory room facilities are located in the basement. All bedrooms are single rooms with en suite facilities. Cost of service £619.87 - £918.05 per week DS0000011024.V367760.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means that people who use this service experience excellent quality outcomes. This unannounced inspection took place on weekday morning and afternoon over the course of five hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the service since the last inspection. Prior to the visit a questionnaire was sent to the Manager along with survey and comment cards for residents and visiting professionals such as doctors and nurses. Any replies were used to help form judgements about the service. Consideration has also been given to other information that has been provided to the Commission since the last inspection. The inspector toured the building, examined records and met all of the residents. The inspector also spent time talking informally to staff and observing how care was being delivered to the residents. From the evidence seen by the inspector and comments received, the inspector considers that this service has a good awareness and understanding of equality and diversity issues and would be able to provide positive outcomes for residents in the areas of race, ethnicity, age, gender, sexuality, disability and belief. The inspector gave feedback about her findings to the homes Manager at the end of inspection. There were no legal requirements made as a result of this inspection. The Commission has received no information concerning complaints since the last inspection. What the service does well: Residents are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. One of the residents said, “there is plenty to do in the home” and another said that they are “never bored”. The home has two full time Activity Co-ordinators who work tirelessly to enhance the quality of life of the residents by providing a varied and interesting activity programme. The home holds a number of themed events throughout the year to promote community involvement. There have been frequent trips out to both the local DS0000011024.V367760.R01.S.doc Version 5.2 Page 6 community and further a field and these visits have been particularly popular with the residents. The service understands and actively promotes the importance of respecting people’s rights to equality, dignity and independence. Appropriate choices are offered to people using the service and they are encouraged to have a say in how the home is run. Routines are flexible and can accommodate people’s individual need. The health and personal care that people receive is based on their individual need. The principles of respect, dignity and privacy are put into practice. The home provides a comfortable environment that is appropriate to the needs of people who live there. The home is clean and well maintained throughout and is wholly accessible to people with physical disabilities. The gardens are very attractive and are well used by residents. The written records are well kept and up-to-date. They provide staff with sufficient information to provide the right care. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. DS0000011024.V367760.R01.S.doc Version 5.2 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 DS0000011024.V367760.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 People who use the service experience good quality outcomes in this area. Residents are fully assessed prior to admission to ensure the home will be able to effectively meet their need. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Admissions to the home are not made until a full needs assessment has been undertaken. For people who are self-funding and without a care management assessment, a skilled and experienced member of staff carries out an in-depth assessment. The assessment usually takes place at home or in hospital and is carried out by the homes Registered Manager or Care Manager who are qualified nurses. Where referral to the home is made by the Local Authority a copy of the summary assessment and care plan is sought. DS0000011024.V367760.R01.S.doc Version 5.2 Page 9 The documentation for eight residents was examined during inspection and these residents were case tracked from pre-admission to date. From discussion with staff, management and residents it is evident that a period of planning is undertaken pre-admission to ensure that the residents needs can be met effectively at the home. This includes ensuring that the home has available any specialist equipment needed by the individual during their stay and ensuring that staff are conversant with the pre-admission documentation. A range of clinical tools were being used routinely to assess the resident’s nutritional needs, communication needs and level of mobility. Manual handling risk assessments and ‘safe systems of work’ had been devised to reduce the likelihood of injury to residents and to staff. A full assessment of the resident’s risk of falls, continence needs and mental state had been carried out preadmission. The inspector had the opportunity to meet one of the residents that was being case tracked. The resident confirmed that they had been visited by the management of the home in hospital pre-admission and had been provided with sufficient information about the home to enable them to make a decision as to whether to live there or not. They confirmed that they had been offered the opportunity to visit the home informally before they were admitted in order to tour the home and meet staff and other residents. DS0000011024.V367760.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 People who use the service experience excellent quality outcomes in this area. Residents are encouraged to make choices about their lives and to take everyday risks. The written records accurately reflect the individual needs, aspirations and lifestyle choices of each resident. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents of the Windmill are fully supported to direct their own care and to be involved in decision making about their own lives. People’s rights to choice, autonomy, individuality and independence are fully recognised and valued by the staff. Care plans are developed with the resident, their family and advocates and address issues of equality and diversity. The plans are holistic in detail and identify people’s personal wishes and preferences in relation to their everyday lives. DS0000011024.V367760.R01.S.doc Version 5.2 Page 11 From examination of the documentation it is evident that care plans are regularly reviewed and updated and any changes to the plan are discussed and agreed with the resident and their family. All risks to residents have been fully assessed using a range of clinical tools and effective guidelines and equipment are in place to reduce the likelihood of occurrence. The care plans are working tools and examination of residents daily records evidenced that the content fully validated the care plans. From discussion with staff and observation of practice it was clear that personal care is provided discreetly and in a manner, which maintained the residents right to dignity, privacy, independence and choice. Residents and their relatives confirmed that access to health and social care professionals for advice and support is provided when needed. Residents regularly see their doctor and referral is made to hospital when necessary for further support and treatment. Screening and preventative treatments are routinely provided to all residents of the home. The Community Matron is a regular visitor to the home and offers advice, support and training to the nursing staff about a range of issues including ‘verification of death’ and ‘End of Life’ care. The home has adopted the ‘Gold Standards Framework’ and works with the GP and Community Nurses to provide appropriate palliative care to residents at the end of their life. The home has robust medication policy, procedure and practice guidance in place. The nurses are aware of their responsibilities in relation to the safe administration of medication and follow clinical guidance. The system used for the safe administration of medication is the monitored dosage system. This system reduces the likelihood of medication error and provides an accurate record of administration. Medication is stored securely and disposal systems are safe. The ‘Doom box’ system has been adopted by the home for the disposal of waste medication and the home has an appropriate contract with a registered disposal company. From discussion with four residents the following comments were recorded “I’ve been here a while, I have everything I need”, “ no one wants to leave their own home, but they do their best here”. “The staff are kind”, “I’ve no complaints”. DS0000011024.V367760.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14, 15 People who use the service experience excellent quality outcomes in this area. A range of activities is offered that provide opportunity for mental and physical stimulation. Residents are encouraged to maintain contact with their family and friends and are able to have visitors at any time. The home provides a varied and nutritious menu designed to meet the needs of its residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of inspection a large number of residents were engaged in sing-alongs, bingo sessions and one-to-one sessions with one of the activity organisers. It was evident that residents were enjoying themselves and there was a lively, cheerful atmosphere in each part of the home. Several residents took part in a ‘lunch club’ in the activity room. This activity is particularly popular with residents of the first floor where people are mentally frail. The activity room is laid out as a small intimate restaurant and residents may eat DS0000011024.V367760.R01.S.doc Version 5.2 Page 13 their meals with a small group of friends whilst they are supervised and waited upon by one of the activity organisers. The residents were clearly enjoying this activity during inspection. The home has won the ‘Slough in bloom’ contest for the last two years and has entered again in 2008 along with the ‘Blooming Marvellous’ competition where the winning home will win £1000 to put towards activities for residents. Residents and staff told the inspector that resident’s work on craft activities and horticultural pursuits throughout the year ready for the judging. The gardens are bright, cheerful and well kept. Six large gazebos were erected in the gardens and during the afternoon a large number of residents played bingo beneath them, enjoying the fresh air whilst shaded from the sun. The home was gearing up for its summer barbeque when local dignitaries, staff, families and residents enjoy musical entertainments in the gardens. This year the home has employed an ‘Elvis’ impersonator to entertain the residents. The home has been taking part in ‘a breath of fresh air’, which aims to provide activities and trips out for all of the residents. The event started with a rock concert in the garden and trips to Saville Gardens, Windsor, pub lunches, ‘The Milestone Museum’, London Zoo, Runnymede and two trips to Brighton. The administrative assistant and handyman are both qualified to drive the shared company minibus to facilitate the trips. This home excels at providing residents with entertainments and activities suited to their needs. The residents meeting minutes indicate that several people have requested a trip to watch the local ice hockey team and residents of the second floor have requested swimming sessions. There are plans to start the swimming sessions as soon as the local baths can provide the necessary coaches. Additionally residents have requested facilities to play snooker and darts and there are plans to convert a small lounge on ‘Tulip’ to a games room. Several residents on the second floor attend a local day centre where they meet their friends and socialise and others have requested to start attending. The home has recently hosted a ‘music to welcome summer’ garden party and a petting zoo. From examination of records it is evident that accurate records are kept of those who have participated in each activity and whether or not they enjoyed it. The Activity Organisers have developed an activities plan for the home for forthcoming months. Special celebrations take part to mark festivals and special birthdays. Funds for any outings and outside entertainment come partly from the homes activity budget and partly from funds that have been raised by the home. It was clear that resident’s capacity to join in with activities varies according to their particular needs, however support and one-to-one assistance is offered on a routine basis. Residents that are bedfast are offered one-to-one DS0000011024.V367760.R01.S.doc Version 5.2 Page 14 manicures, hand massage and can be chatted or read to. Efforts are made to engage with all of the residents on a daily basis. Residents may have visitors at any time and relatives confirm that they are always made welcome and are offered appropriate hospitality during their visits. The routines at the home are flexible and are designed to offer residents choice and autonomy. Residents can rise and retire at a time of their choosing. They can choose whether to be alone or in company and may wander freely around the home and gardens. Policies, procedures and practice guidance at the home focus on residents being empowered to take control over their own lives. Residents regard the food they are given as one of the most important factors in determining their quality of life. All of the residents confirmed that the food was good. There is a choice of meals at each mealtime. The home is able to cater for a range of special diets and cultural menus including diabetic diets and vegetarian diets. Halal meats and Kosher food are provided when needed. DS0000011024.V367760.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 People who use the service experience good quality outcomes in this area. The home has a satisfactory complaints system. Residents feel their views are listened to and acted upon. Residents are protected from abuse and exploitation by well-trained and competent staff that can demonstrate knowledge of the homes abuse of vulnerable adults and whistle-blowing policies. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents confirmed that any concerns or complaints would be taken seriously by the home and efforts made to remedy any problems in a timely fashion. Residents felt that management were accessible and approachable and operated an ‘open door’ policy, which enabled them to address issues quickly before problems escalated. The complaint policy in the home meets the requirement of Standard and Regulation. Residents and relatives are provided with information on how to make a complaint to the home and the formal stages in procedures. Examination of the complaint records indicated that there has been one complaint made to the home since 1st January 2008. The details of the DS0000011024.V367760.R01.S.doc Version 5.2 Page 16 complaint was well documented and indicated that an investigation had taken place and an outcome had been provided to the complainant. There has been no information about complaints reported to the CSCI about the home since the last inspection. There was evidence in staff files and from discussion with staff, that they receive training in ‘Safeguarding Adults’ as part of their formal induction to the home which is later consolidated when undertaking NVQ training in which it forms a core module. There is one unresolved safeguarding issue, which is being dealt with by the Local Authority in line with local ‘safeguarding protocols’. All of the residents, relatives and staff have recently been involved in an ‘Elder Abuse Awareness’ day when they have learned about what constitutes abuse and how to identify and report it. All of those involved found the event most helpful. Observation of care practice concluded that staff were patient and understanding when dealing with residents and appeared mindful of the need to respect their privacy and dignity. Staff interviewed were aware of the homes whistle-blowing policy and understood the importance of protecting residents from abuse and exploitation at all times. The residents confirmed that they felt safe and well cared for. DS0000011024.V367760.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19 & 26 People who use the service experience good quality outcomes in this area. The standards of décor and furnishings in this home offer residents a comfortable and homely place to live. Standards of hygiene are good throughout. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From a tour of the building it is clear that the home is well maintained for the benefit of residents. All communal areas were clean, airy and well lit and were decorated and furnished to a comfortable standard. The home has a rolling programme of routine maintenance and renewal and a budget is available that reflects this. The bedrooms were all personalised and were warm spacious and comfortable. The home has a range of aids and equipment available to maintain residents independence and to promote safe care. Profiling beds are DS0000011024.V367760.R01.S.doc Version 5.2 Page 18 available for residents that need them and specialist mattresses are used routinely to promote tissue viability. There is a choice of bathing and showering facilities both assisted and unassisted and there are sufficient toilets placed strategically around the home to meet the needs of residents. All bathrooms, toilets and sluices have a supply of liquid soap and hand towels to maintain satisfactory infection control standards. The home was clean and hygienic throughout there were no residual odours noted. Residents confirmed that the home is always clean and well maintained and staff work hard to provide a pleasant environment for the residents. Discussion with staff and examination of the staff training records evidenced that all staff have received refresher training in infection control and health & safety. DS0000011024.V367760.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29, 30 People who use the service experience good quality outcomes in this area. There were sufficient numbers of staff on duty at the time of inspection to meet the needs of residents effectively. The skill mix of the staff team was appropriate for the size, layout and purpose of the home. Recruitment policies and procedures at the home are robust and transparent and ensure the safety of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector examined three of the recruitment files. The content indicated that all necessary checks are undertaken on prospective staff to ensure the safety and protection of residents. Records were well kept and met the required standard. The qualifications of nurses have been checked effectively to ensure they are fit to practice. The nurses Pin numbers and Statement of Entry on the Register were well recorded and up-to-date. All nurses are provided with regular refresher training as part of their personal development. Two of the senior nurses have responsibility for ensuring all training is up-to-date at the home DS0000011024.V367760.R01.S.doc Version 5.2 Page 20 and have developed a training matrix a copy of which is on the wall of the office to aid access and clarity. A number of the current workers from overseas are being provided with English language skill training. The training is being sourced from ‘Skills to Care’. The language training has had a beneficial effect on residents and has helped improve communication between the members of the staff team as a whole. It is evident from discussion with staff that they are highly motivated and keen to learn new skills. Staff interviewed formally by the inspector appeared to have a good understanding of their role. They understood the need to ensure that the residents were well cared for. They were well trained, well motivated and cheerful. There was evidence in the staff files that care staff have been properly inducted to Skills for Care standard and have received training in core skills such as fire safety, first aid, manual handling, food hygiene, health & safety, COSHH and infection control. All staff have received training in ‘Safeguarding Adults’ as part of their induction and as a core module in NVQ training. All staff at the home are well motivated and have either achieved or are working towards a National Vocational Qualification at level 2 or 3. All staff receive support on an on-going basis. They receive formal supervision at least six times a year and have additional opportunities to air their views and to have a say in the way the home is run in the team meetings. Staff said that they enjoyed working at home and looked forward to coming to work. Residents and visitors were highly complimentary about the quality of the staff employed at the home. One resident said “ the staff are very good here” another said, “I never have any problems the staff come when I need them to help me”. DS0000011024.V367760.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 31, 33, 35, 38 People who use the service experience good quality outcomes in this area. The resident’s benefit from living in a well managed home, where there is evidence that there health, welfare and safety is of primary importance. The registered person is qualified, competent and experienced to run the home for the benefit of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager – Gertrude Mashungupa is a is a qualified and highly experienced nurse who has enhanced and updated her skills and knowledge by completing a Diploma in Business Management and the Registered Managers Award. Gertrude is a trainer in manual handling and a qualified counsellor. She works entirely off of the roster so that she may concentrate on her management duties. A competent deputy, team of senior nurses, administrator DS0000011024.V367760.R01.S.doc Version 5.2 Page 22 and skilled carers and ancillary staff support the Manager in her work role. A number of the staff team have worked in the home for several years and know the residents well. There is a low rate of turnover amongst the staff team and little reliance on agency workers to cover gaps in the roster. Residents are highly complimentary about the management of the home and feel that they are kept well informed of what is going on. Residents say that the manager is always open and accessible and makes time to speak with them on a regular basis. They confirm that they are regularly consulted on issues that affect them and feel that their views are always taken into account. The Manager holds a surgery every Wednesday evening between 5 & 7pm in order to meet with families and discuss issues as they arise. These meetings facilitate effective communication between the home and residents relatives. From examination of the minutes of residents meetings it is clear that when requests are made or concerns expressed the issues raised are followed up promptly by management. The home carries out a number of quality assurance checks and uses the information gathered to monitor how well the home is meeting its aims and objectives. The home is pro-active in monitoring its own performance against quality standards. A Senior Manager from Southern Cross visits monthly and completes a Regulation 26 report. The last three reports were examined as part of this inspection and were seen to accurately identify the homes strengths, weaknesses and shortfalls and to actively seek resident’s views. An examination of the homes quality audits evidenced that it seeks the views of residents, relatives and staff on an annual basis. The results of the annual survey are used by the home to measure its success in meeting its published aims and objectives. The home also regularly audits training, the environment, meal provision, health & safety and accident trends and identifies where it can make improvements. The home works closely with two of its sister homes in the area and management meet regularly to share good practice and exchange resources. Staff are occasionally asked to cover for absences in one of the other homes or are offered overtime. The home is careful to ensure that there is no detriment to the quality of service provided by the Windmill. The inspector had the opportunity to discuss the procedure for administering resident’s cash accounts with the homes administrator and to examine financial records. All financial records were accurately kept and were well documented. Southern Cross Healthcare has a robust system in place, which is open, transparent and fair. Residents receive interest on any monies held on their behalf and a foolproof system is in operation for the safe deposit or withdrawal of resident’s monies. Receipts are kept of all cash spent. Most DS0000011024.V367760.R01.S.doc Version 5.2 Page 23 residents have family members that deal with their financial affairs and only small amounts are deposited with the home. Examination of a sample of the homes health & safety records indicated that they were up to date and in good order. Routine servicing and maintenance of equipment is undertaken at appropriate intervals to maintain the home as a safe and risk free environment for residents. The home shares a full time handyperson with a neighbouring home, which enables the home to act promptly to remedy any maintenance deficits. All identified risks are effectively risk assessed and managed. To highlight health and safety action in the event of a fire at the home the local Fire Brigade provided all staff and residents with a talk. People that attended found it helpful. DS0000011024.V367760.R01.S.doc Version 5.2 Page 24 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 3 x 3 DS0000011024.V367760.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 DS0000011024.V367760.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000011024.V367760.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!