Inspection on 09/03/07 for Windmill House

This inspection was carried out on 9th March 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Windmill House 15/03/06

Windmill House 18/03/05

Windmill House 30/11/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Windmill House Alveston Road Tockington South Glos BS32 4PH Lead Inspector Jon Clarke Key Unannounced Inspection 9th March 2007 09:30 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 Windmill House DS0000003337.V328335.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. Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windmill House Address Alveston Road Tockington South Glos BS32 4PH 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) 01454 413818 Windmill Care Limited Mrs Katharine Rachel Collacott Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 37 persons aged 65 years and over requiring personal care 15th March 2006 Date of last inspection Brief Description of the Service: Windmill House is registered as a private residential care home providing accommodation and personal care for up to thirty-seven older people aged sixty-five years and over. The home is owned and operated by Windmill Care Ltd a company owned by Mr and Mrs Collacot. Mrs Collacot is the registered manager. Windmill House is situated in the hamlet of Old Down, close to the village of Tockington where there are shops and other village amenities. The home is on a bus route to the town of Thornbury approximately two miles away where there are a variety of services and facilities. Transport is provided by the home. The home is a period, detached house set in its own grounds, which has been extended. An additional new wing was built in 2004 that provided a further seven en suite rooms and additional lounge space. The original house has three floors with many character features. The more modern extension to the house is on two floors. The new wing is at ground level. A passenger lift and stair lift provide access to all floors. There are well-established gardens that offer sitting areas and level walks with attractive features. Most rooms overlook the garden and communal areas have aspects into the garden. Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day the manager was present throughout the inspection. As part of the inspection a number of records and documents were examined including care plans, staffing recruitment and training, medication administering and storage arrangements and health and safety. There was an opportunity to discuss with residents and staff their experience of living and working in the home. Prior to the inspection Have Your Say questionnaires were sent to residents and relatives, there were 11 and 12 respondents respectively. These helped to inform the inspection and making a judgement about the quality of care provided at Windmill House. What the service does well: What has improved since the last inspection? Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 6 A number of requirements were made at the last inspection. They related to health and safety practice in the home maintaining a safe environment for residents of the home. Areas identified included safe water temperatures, fire drills and ensuring security of residents in the event of a fire. These areas have all been addressed improving practice and the environment of the home. 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. Windmill House DS0000003337.V328335.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 Windmill House DS0000003337.V328335.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes full and comprehensive assessment of prospective residents so that they are able to make an informed decision about the capacity of the home to meet health and social care needs. EVIDENCE: A number of admission records were examined and these included copies of the home’s assessment and where an individual was known to the local authority a copy of their assessment. The Pre Admission assessment included information about the physical and health needs of the individual and also provided a way of establishing the dependency level of the individual. Included in the assessment is information about the social needs, personal history and daily routines, interests of the perspective resident. Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 9 Windmill House DS0000003337.V328335.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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care Planning and arrangements for meeting health care are good providing staff with the necessary information so that the health and social care needs of residents are met. Arrangements for the management of resident’s medication make sure that resident’s health needs are protected. The practice of staff and policies of the home help to make sure that residents are treated with respect and their dignity is upheld EVIDENCE: A number of care plans were looked at and showed good information about individuals. Included was Past History, Assessment of daily living, (routines, waking, meals, personal hygiene and diet) Risk assessment had been completed specifically where the individual was at risk of falls. Manual handling risk assessments had also been completed and these had been reviewed as Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 11 part of the care plan review. Reviews had been held regularly and a review takes place which includes resident and relative. Community based health services such as podiatrist, dental are provided in the home and district nurses provide nursing care where this is required. In response to questionnaire all respondents said they “always” received the medical support they needed. Comment from podiatrist “my treatment plans for residents are always carried through. I am confident that if any problems or concerns occur the staff will contact me promptly” and district nurse stated, “staff are always helpful and extremely knowledgeable about clients”. Arrangements for the managing of medication were looked at and there was good storage in place. Administering records had been completed as required. At present there are three residents who manage their medication, risk assessments had been completed. At present there are no residents who have been prescribed controlled drugs in this event the home would need to have separate controlled drug storage. This was discussed with the manager at the time of this inspection. In talking with residents they spoke positively of the approach of care staff “they are always patient and caring” “treat you with respect”. In observing staff they interacted with residents in a supportive and appropriate manner. In one instance a member of staff was observed assisting a resident to the toilet and this was done in a sensitive and quiet way. Comments were received from relatives illustrating how staff are viewed with regard to how they relate to residents: “dignity is always respected” “staff are friendly and kind and do respect the residents wishes to live the life they choose” “treat residents with respect and value and welcome their opinions”. Windmill House DS0000003337.V328335.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for meeting the social and recreational needs of residents are good and there are opportunities for residents to maintain links with family, friends and the local community. The home’s practice and routines are flexible and enable residents to exercise choice and have control over their lives. The home provides meals, which are balanced and meet the dietary needs of individuals in the home. EVIDENCE: In talking with residents they spoke of a range of activities organised in the home including crafts, cooking, exercise and games. Trips are organised and residents had made suggestions about where to visit. Staff are also able to accompany residents shopping. Monthly communion is held in the home. The home has an inviting environment and a resident spoke of how when they had visitors they were always “made to feel welcome”. One relative said how the home had a “friendly welcoming environment”. Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 13 In talking with residents about the routines of the home they spoke of how they were able to choose “how I spend my day” “its up to me” One resident when asked about getting up and going to bed said how “I can choose its up to me”. A note in the daily record also illustrated the approach of staff it related to a resident who “didn’t want to get out of bed so let (?) her lay in”. Residents all spoke positively about the food provided in the home returned questionnaire in response to: Do you like the meals in the home? 6 responded always 5 usually. Residents when asked said there was always a choice and menu seen illustrated this with an emphasis on home cooked foods. . Other comments included “food is always good” “I always enjoy my meals here” “its one of the best things about here”. The home has also received a four star rating from Gloucestershire environmental health reflecting good hygiene and health and safety practice this is to be commended. Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 14 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): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has clear procedures in place and this enables individuals to make a complaint and voice their views about the service they receive and to know that they will be listened to and actions taken where necessary. The home makes sure that as far as possible residents are protected from harm by having policy and procedure about the Protection of Vulnerable Adults and providing Adult Protection training to staff however not all staff have completed this mandatory training. EVIDENCE: The home has a clear complaints procedure and when asked residents were aware of this procedure. All respondents to the questionnaire said they knew how to make a complaint. When asked residents said they “would always say” if they were unhappy about anything and others spoke of how approachable the manager was and how they would speak to her if they had worries or concerns. No complaints had been made since the last inspection. The home has an Adult Protection and Whistle Blowing policy and this forms part of staff induction. There remains some staff who have not received Adult Protection training. The manager and deputy have undertaken the South Gloucestershire Adult Protection training. The home has an Abuse Awareness Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 15 video which staff watch and are then required to complete a questionnaire afterwards. Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 16 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): 19,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe and hygienic environment for the residents and staff. EVIDENCE: In walking around the room it was very evident that there is a high standard of cleanliness and residents confirmed how the home is always clean and free from unpleasant odours as on the day of this inspection. It was also very evident that the owners and managers have made a real effort to provide a homely environment with well-furnished communal areas. There are a number of seating areas providing a choice of areas for residents as to where they can sit. The main lounge is a bright and inviting space Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 17 overlooking the extremely attractive and well-maintained gardens. A number of residents commented to the inspector how much they enjoyed the gardens. Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 18 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): 27,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing arrangements in the home are good making sure the needs of residents can be met in an efficient way with care being provided by skilled and competent staff. The health and welfare of residents could be improved by making sure there are always staff on duty who are first aid trained. The recruitment and selection of staff is undertaken to make sure that as far as possible the health and welfare of resident is protected. EVIDENCE: Staffing rotas were examined and showed a good level of staffing in the home and taken against the identified needs of residents provide sufficient staff to meet those needs. There are 6 staff on duty am, 4 pm with 2 waking night staff. Respondents to the pre-inspection questionnaire said that Staff ‘always’ available when you need them (10) usually (1). One resident spoke of how the staff were all very good and how “you get all the help you need” Recruitment and selection records were looked at and showed that the necessary checks are place ie 2 references and Criminal Record Bureau (CRB) Application forms provided full and detailed information about applicants including full employment history as required. Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 19 Training records were looked at for a number of staff including 2 night staff (2 night staff had no training recorded). There were inconsistencies in the training in that whilst a number of staff had completed mandatory training in moving and handling, first aid, fire safety there were a number specifically night staff who had not done so particularly first aid. In addition only one of seven staff had evidenced Protection of Vulnerable Adults training. Staff spoke of receiving additional training such as mental health and physical disability. Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 20 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): 31,33,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good opportunities for residents and others to express their views about the service they receive. This should be improved by introducing a formal method of quality assurance questionnaires. The practices of the home help in making sure that the health, safety and welfare of residents and staff is protected. There is good practice in the supervising of staff. EVIDENCE: Mrs Collacott is the registered manager and co-owner of Windmill House and has run the home since 1998 with her partner as part owner. Mrs Collacott has a nursing background, has NVQ registered manager award and is a NVQ Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 21 assessor. She is clearly seen by residents and staff as approachable and open in her approach and in discussing residents clearly had a real understanding and knowledge of individuals in the home. Staff described her as supportive and very in touch with the day-to-day life of the home. Mrs Collacott places great importance on making sure there are opportunities for residents to express their views about the quality of care provided in the home. Regular residents meeting are held and minutes showed that residents used these meetings to make suggestions and voice their concerns. One resident said that she enjoyed these meeting and always felt they were “listened to and something is always done”. However there is no formal way for residents to express their views or for others such as relatives and professionals who visit the home to do so. This would provide further evidence that the manager is reviewing and making changes where necessary with regard to the quality of care provided. Supervision records were looked at for seven members of staff and showed that the home has improved its practice around supervision with all having received supervision regularly (over 6-8 week period). Staff meeting are held though the manager acknowledged this is area that could be improved in terms of frequency of such meetings. Records relating to health and safety practice in the home were examined and showed that the necessary fire drills, alarm tests (weekly) are undertaken however emergency lighting tests on monthly basis are not completed. Fire system inspection took place 09/08/06. Maintenance of equipment such as lift (17/01/07) and stair lift (17/01/07). An environmental health inspection of the kitchen took place on 28th March 2007 and made a number of recommendations regarding improving the kitchen environment. The manager informed the inspector these are to be followed up with work to modernise the kitchen facilities. Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 22 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 3 X 2 Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP30 Regulation 13 (1) 18 (1) Requirement Timescale for action 30/06/07 2 OP18 13 (6) 18 (1) 3 OP33 24 (1,3) 4 OP38 13(4) c Ensure there are arrangements for staff to be trained in first aid and that at all times there is staff member on duty who is first aid trained. (This specifically refers to having night staff who are first aid trained) Ensure all staff undertake 30/06/07 mandatory training to include Vulnerable Adults, Moving and Handling, Health & Safety, Fire Safety. Record of staff training to be available for inspection. Ensure there is consultation and 30/09/07 quality assurance system in place that involves the use of questionnaires. That regular reviewing and where necessary improvements take place in relation to the quality of care provided in the home. (This refers to having a formal method of seeking the views of residents and others about the quality of care and an opportunity to make suggestions about improvements which could be made) Ensure monthly checks take 01/04/07 place on emergency lighting. DS0000003337.V328335.R01.S.doc Version 5.2 Windmill House Page 24 (Requirement from previous inspection not met) 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 Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Windmill House DS0000003337.V328335.R01.S.doc Version 5.2 Page 26 - 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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