Inspection on 11/04/07 for Windmill Lodge

This inspection was carried out on 11th April 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 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 Lodge 21/11/05

Windmill Lodge 13/06/05

Windmill Lodge 13/12/04

Windmill Lodge 24/08/04

Windmill Lodge 13/02/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Windmill Lodge 2 Windmill Hill Buntingford Hertfordshire SG9 9JP Lead Inspector Yoke-Lan Jackson Unannounced Inspection 11th April 2007 10:00 Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 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 Lodge DS0000019623.V335625.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windmill Lodge Address 2 Windmill Hill Buntingford Hertfordshire SG9 9JP 01763 273935 01763 274303 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) Mrs Mary Alcock Miss Julie Hubbard, Mr Hedley Alcock Miss Julie Hubbard Care Home 6 Category(ies) of Learning disability (5), Learning disability over registration, with number 65 years of age (1) of places Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2005 Brief Description of the Service: Windmill Lodge was a family house that was converted into a care home in 1995. The home offers a safe, secure and caring environment for its residents who are adults with learning disabilities. It is situated at the end of a cul-de-sac in a residential area of Buntingford and is within walking distance of local amenities. Hertfordshire County Council owns the property but the home is managed by a private partnership, which is responsible for the maintenance of the building. It blends in very well with the surrounding residential properties and comprises six bedrooms, two bathrooms, a shower room, two lounges, a dining room and a good-sized kitchen. There are large gardens to the rear and side of the property and good parking to the front. The home charges £1120 per week. Further information can be obtained from the Statement of Purpose and the Service User Guide. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection included a site visit on 11/04/07. The registered manager was present. There are five people living in the home and one vacancy. One of the residents is currently in hospital. The inspection included a tour of the premises. Staff and residents were interviewed. Documents were examined. (See below for details of the inspection findings) What the service does well: What has improved since the last inspection? The management has devised a “Training Pathway” providing a clear guide to the training programme to ensure the care needs of residents are being met consistently. All members of staff have completed NVQ2 and five members of staff have completed NVQ3. The written care plans have been revised. They are comprehensive and well structured to include people-centred information. The home has attained several awards, including, Health and Safety Award, July 2006, Food Hygiene Award, July 2006, Safer Food Award and Heartbeat, Healthy Living Eating Award. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about the service provided in the home. A pre-admission assessment is carried out before a prospective resident is admitted. The home will only admit a prospective resident whose care needs can be met. EVIDENCE: The home has a Statement of Purpose that is available in an alternative format. A Service User Guide is given to each resident. The home has block contracts arranged with Hertfordshire Social Services. There have been no new admissions since the last inspection. One resident is currently in hospital. He will be reassessed before he is transferred back to the home. The staff are confident that his care needs will be met adequately when he returns. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 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. Residents are assisted to lead independent lifestyles and their assessed and changing needs are reflected in their written care plans. EVIDENCE: The inspector met four residents during the site visit. They appeared relaxed and well cared for. The home has a key-working system to ensure that each resident is consulted on all aspects of life in the home, and that they are supported in the choices that they have made. The care plans have been revised since the last inspection. They now include people- centred planning. The information provided are comprehensive and well structured. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to lead an independent lifestyle and they integrate into the community through an outdoor activity programme. They have close links with their families. Residents are encouraged to adopt a healthy living lifestyle. EVIDENCE: Each resident has an individually planned activity and educational programme arranged to meet their needs and promote their skills and interests. One resident said that he “travels on the bus to the local shopping centre” by himself. On the day of the inspection, two residents showed the inspector the vegetable garden that they have helped maintain as part of their outdoor activity programme. The home offers a nutritious and varied menu chosen by the service users themselves. A dietician is involved to ensure that the food provided is Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 11 nutritious and balanced. Members of staff take turns to prepare the meals, using freshly grown vegetables from the garden whenever available. As a means of enabling the residents to be more fully involved in the planning and preparation of their meals, several of them now assist the staff to purchase the food from a local supermarket. On the day of the inspection, two staff accompanied two service users to the supermarket to get their weekly supplies. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal and health care needs are being met. A trained member of staff administers the medication as residents are not able to administer their own. EVIDENCE: On the day of the inspection, it was noted that members of staff interacted well with the residents, who appeared cheerful and contented. Any health and behavioural concerns are referred to the appropriate healthcare professional for immediate assessment. During the week, a resident was admitted to hospital following a referral to the Community Psychiatric Team. On the day of the inspection, there was one resident waiting for admission to a local hospital for a tooth extraction. He seemed relaxed and well supported by the member of staff who later accompanied him to the hospital. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 13 All members of staff have appropriate training to administer medication. The home uses the Nomad system for each service user. The Medication Administration Record charts examined showed colour highlights, a practice of the local chemist. The manager ensures that the protocol agreed with the chemist is made clear to all members of staff. The MAR charts were accurately recorded except for one where a sticker label was used. The manager has since taken this up with the pharmacist to ensure that the use of sticker labels is discontinued as stipulated by the Royal Pharmaceutical Society. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a robust Complaints Policy and Procedure to safeguard service users. EVIDENCE: The CSCI written feedback forms suggest that residents are aware of the home’s complaints procedure, and that they know who to speak to if they need assistance. The home follows Hertfordshire Social Services’ Procedure in the event of an abuse incident. The Commission, CSCI, has not received any complaint about the service since the last inspection. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment. There is an ongoing and planned maintenance programme. EVIDENCE: On the day of the inspection, the home appeared neat and tidy. The residents said that members of staff assist them to clean their bedrooms. The bedrooms inspected reflect the lifestyle of the occupants. One resident said, “I enjoy living here”. It was noted that the positioning of the clothes line was a hazard to safety. Since the inspection, the clothes line has been replaced. The bathroom on the first floor is not accessible until repair work is completed. However, residents have access to the bathrooms and toilet facilities on the ground floor. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective staff team. Staff have a good knowledge of residents’ care needs and aspirations. EVIDENCE: There are two teams of staff. Each team consists of an assistant manager and three support workers and they cover a shift. Team working was evident on the day of the inspection. All members of staff have NVQ2 and five members of staff have achieved NVQ 3. The registered manager has designed a training programme guide called “Training Pathway” to encourage all members of staff to have ongoing training towards attaining NVQ4. Members of staff interviewed confirmed their training and educational achievements. They have a good knowledge of the healthcare and personal care needs of the residents. Since the inspection, the registered manager has arranged for some staff to have further training on medication and health and safety issues to ensure that residents are safeguarded at all times. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 41, 42, 43. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The administration and management of the home is to a high standard. The health, safety and welfare of residents are protected and their best interests are safeguarded. EVIDENCE: The home is very well managed. The registered manager is one of three proprietors who are all hands-on in their approach to managing the service. In a written survey by CSCI, one healthcare professional commented, “Windmill Lodge works well within the multidisciplinary team”. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 18 Another professional commented that the staff are consistent in their approach to dealing with residents’ behavioural and care needs and that they “communicate well with each other and they deal with the multidisciplinary team effectively”. The home’s policies and procedures and the records for the protection of residents are well maintained and they are kept up to date. There is an effective quality and monitoring system. There is a business and financial plan that is available for inspection. The home has attained several awards including, Health and Safety Award, July 2006, Food Hygiene Award, July 2006, Safer Food Award and Heartbeat, Healthy Living Eating Award. These award certificates are on display on the wall in the administrative office together with the Registration Certificate and the Liability Insurance Certificate are on display on the wall. Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 4 3 3 3 3 3 3 Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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 Windmill Lodge DS0000019623.V335625.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Hertfordshire Area Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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. 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