Inspection on 26/07/06 for Windmill Lodge

This inspection was carried out on 26th July 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Windmill Lodge 14/03/08

Windmill Lodge 17/10/05

Windmill Lodge 05/05/05

Windmill Lodge 30/11/04

Windmill Lodge 05/07/04

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Insight - Eastchurch

Southfields

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

CARE HOME ADULTS 18-65 Windmill Lodge 26 Springhead Road Northfleet Gravesend Kent DA11 9QY Lead Inspector Anne Butts Unannounced Inspection 26th July 2006 10:00 Windmill Lodge DS0000059514.V306017.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 DS0000059514.V306017.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 DS0000059514.V306017.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windmill Lodge Address 26 Springhead Road Northfleet Gravesend Kent DA11 9QY 01474 354212 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) joehosanee@tiscali.co.uk Mr Abdoollah Hosanee Mr Abdoollah Hosanee Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th October 2005 Brief Description of the Service: Windmill Lodge provides accommodation and support for up to eight people with learning and some physical disabilities. Twenty-four hour care is provided. All service users have single en-suite bedrooms. There is a garden at the rear and a patio area at 1st floor level. The premises are about 15-20 minutes walk from the centre of Gravesend and there is easy access to public transport and to a range of amenities. The Owner/Manager is nurse trained (RNM and RNMH), has a diploma in management studies and has achieved the Registered Managers Award. He manages the home on a daily basis and is supported by a Deputy Manager. The current fee structure at the time of inspection was £581.00; there are additional charges for hairdressing, clothes, toiletries, activities and holidays. Windmill Lodge DS0000059514.V306017.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 key inspection that took place over the course of one day. It took into account a thorough look at how well the service is supporting service users in the home. Information relating to the inspection was gained through details provided to The Commission by the home in the form of the Pre-Inspection Questionnaire, and surveys provided by service users, families and professionals. During the course of the visit documentation within the home was viewed and case tracked. A tour of the premises was undertaken and observations made. Discussions were held with the manager and a number of staff members. Time was also spent talking to people living in the home. This was a positive inspection with excellent feedback given with regards to the care and support provided in this home. Comments included: “I always find the staff very friendly and accommodating” “There is always a very happy and homely atmosphere here” “We are very pleased with the home, my niece has made real progress since moving in here”. There are some good practice recommendations made within this report, however these were discussed at the time of the site visit and the owner and deputy manager advised at this time how they would address these. What the service does well: What has improved since the last inspection? Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 6 Care plans have been improved upon with a new format that is person centred and is supported by risk assessments. The home has taken steps to ensure that service users with additional specialist needs are supported with the extra equipment that will ensure risks associated with their conditions are reduced. A new washing machine has been purchased and a new fridge, freezer and tumble dryer were due for delivery. The home has recently introduced a new questionnaire for service users that promotes their participation in the care that they receive and takes into account future aspirations and goals. 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. Windmill Lodge DS0000059514.V306017.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 DS0000059514.V306017.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Prospective service users are fully assessed prior to moving into the home to ensure assessed needs can be met. Service users and their families benefit from having the opportunity to visit the home prior to admission in order to ensure that it will meet their needs. EVIDENCE: There is a full pre-admission assessment carried out for all prospective new service users that covers all areas of personal, health, behavioural needs and takes into account educational and employment aspirations. An assessment is carried out prior to a new service user moving into the home and ongoing needs are monitored. The home is pro-active in ensuring that the ongoing and changing needs of the service users are monitored and promoted. Service users (and their families or advocates) are encouraged to visit the home prior to moving in and spend time meeting staff and service users. All service users are provided with an individual contract that protects their rights for living within the home. Windmill Lodge DS0000059514.V306017.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Service users benefit from comprehensive care plans which are aimed at supporting them in meeting individual needs. However their safety would be further by protected by risk assessments that are reviewed on a regular basis. Service Users are supported in making decisions about their lives, and are consulted about decisions made within the home. EVIDENCE: The deputy manager has spent some considerable time developing the care plans for individual service users. The format is now user friendly for the staff and enables them to be aware of the needs of individual service users and how to support them in meeting their needs. The care plans take into account agreed aims and objectives and how service users will be supported in meeting these. There are assessments in place of individual strengths and needs. The home has good links with Care managers and regular reviews take place for service users – although the home does not always obtain the outcomes of Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 10 these in writing and they need to ensure that they have access to appropriate information to enable them to fully support service users. Service users are supported to make decisions about their daily lives and this is evidenced through their care plans. Service users spoken to were able to demonstrate and discuss the choices that they made, and how they are involved in activities within the home. The core objective of this home is to promote and support the independence of the service users. A high emphasis is placed on this with assessments supporting individuals’ rights to be as independent as possible. There are comprehensive risk assessments in place in order to support service users, however they need to be reviewed on a more regular basis and incorporated into care plans. A recommendation is being made with regards to this. Overall service users needs are well managed and they are supported in maintaining their independence. Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Service users have opportunities for personal development through education, work placements and a range of community and recreational opportunities enabling the individual to benefit from appropriate and fulfilling lifestyles. Service users benefit from meals that support choice and offer a balanced and nutritious diet, however food storage would benefit from improved monitoring. EVIDENCE: Service users are encouraged to undertake different activities that suit their needs, with some attending work placements, day centres and the Mencap community awareness centre. This allows for individuals to be promoted in maintaining and developing life skills, and supports the homes overall ethos of ensuring that service users lead a fulfilling, independent lifestyle as possible. Service users have the benefit of transport in the home’s minibus and this allows them to be able to go and about on a regular basis including day trips to Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 12 the coast and other places of interest that the service users are able to help choose, go out for meals, bowling and shopping. A service user spoken to described a recent outing to Dymchurch, which he stated, “It was a good day, we really enjoyed it”. Service users are also planning a holiday to Devon in September, although the cost of the holiday is not included in the basic contract price (as stated in Standard 14.4), the home supports service users to budget for the holiday and service users spoken to were all looking forward to their holiday. Service users are fully involved with different aspects of the home and are encouraged to participate in daily living activities and take some responsibility with regards to their own daily chores, including helping out with some duties around the home and maintaining their own bedrooms. Individuals are also supported to make their own sandwiches, microwave meals and drinks. Family involvement is also promoted and a service user stated, “My family can visit whenever they want and I see them a lot”. The home also promotes family involvement with regards to any changing needs. Comments received in surveys from family members included “we are very pleased with the home” and “every time I visit Windmill Lodge everybody is really friendly and I am made welcome”. The home promotes a healthy eating programme and service users are actively involved in choosing menus and going shopping. The site visit was undertaken during the heat wave, and at this time service users preferred to choose meals on a daily basis rather than a planned menu due to the hot weather and they were being supported in this. Food storage was largely appropriate, however dates of when jars and packages was not being recorded and some foodstuffs that needed to be refrigerated once opened were being stored back in the cupboards. A recommendation is being made with regards to this, although the home immediately addressed this at the time of the site visit and disposed of any open jars etc that were not being stored appropriately. Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The personal and health care needs of residents are well met, promoting and protecting residents’ privacy, dignity and independence The service users’ welfare is largely protected by the home’s policy and procedures with regard to the handling and administration of medication; however, improved storage and record keeping would further protect service users safety. EVIDENCE: Care plans demonstrated how staff assist service users with any personal care if needed, and this is carried out in a sensitive manner with procedures in place. Service users spoken to confirmed that staff treat them with respect and they have confidence in the staff in the home. Comments from service users included “I’m very happy here and the staff are really nice to me” and “The staff treat me really well and always listen to what I have to say”. Healthcare needs are well provided for and records evidenced that the home monitors service users needs to healthcare and supports them in attending appointments for the G.P., Dentist, Optician and any specialist needs for Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 14 individual service users. There was some inconsistency with the daily recording of visits to healthcare appointments – there were systems in pace but these were not always being completed. This was discussed at the time of the visit and the deputy manager resolved to address this with staff immediately following the site visit. Individual healthcare needs are taken into account and the home has arranged for the safety of a service user who has epilepsy to be monitored through the night by the means of a vibrating pad that is placed unobtrusively in the bed and can alert staff if the service user suffers from a seizure. They have also purchased a special pillow to further protect the safety of the service user. The home has also taken steps to ensure that a service user who has a hearing impairment will be alerted if the fire alarm is activated during the night and this includes a light and a buzzer under the pillow which vibrates. All arrangements for additional needs are carried out in agreement with the individual service users. Medication was inspected and overall there were good systems in place and MAR sheets were filled in appropriately. The actual storage of medication needed to be improved as medication that needed to be returned was mixed in with medication that was currently in use and there was some outdated medication still being stored that needed to be returned to dispensing pharmacy. There are records to show the audit trail of medication into and out of the home. It is good practice to date when individual boxes and bottles are actually opened and a good practice recommendation being made with regards to this. Only staff who are in receipt of accredited medication training assist service users with their medication. There are currently no service users who administer their own medication but the home is looking as to how to give any individuals the appropriate support if they are assessed as being able to manage their own medication. Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The home has a clear and effective complaints system in place and service users are protected by staff that is trained in adult protection policies and procedures. EVIDENCE: There is a complaints procedure in place and service users are encouraged to put any complaints in writing and these are acted upon with records good records maintained. Individual people spoken to confirmed that they were confident that they could speak to staff if they had any problems. Staff are trained in Protection of Vulnerable Adults (POVA) protocols and no member of staff starts prior to having a satisfactory Criminal Records Bureau (CRB) check being undertaken. One service user is subject to power of attorney and no-one in the home acts as an appointee for handling service users monies. Records are kept of how the home supports service users with their personal monies. Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Service users benefit from living in a safe, largely well-maintained, clean and homely environment which offers privacy and comfort, reflecting individual tastes so enabling service users to live in a ‘homely’ environment. EVIDENCE: A full tour of the environment was undertaken and overall the home was clean and well maintained. Service users and members of staff have the use of a kitchen, a 1st floor level patio area at the rear of the home, a dining area, lounge and rear garden. Overall the home was decorated in a homely and comfortable manner. There are no shared bedrooms and all are en-suite. One service user stated “I like living here, I don’t have to share my room and I can have my own things with me”. A selection of bedrooms was viewed and they reflected individual choices and personal belongings. The rooms are spacious and service users have been able to personalise their rooms and these are decorated to a good standard. They have been able to choose their own colour schemes and the owner stated that when new people move in the rooms are redecorated in Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 17 agreement with their choices. Service users are able to keep keys to their own rooms and records are maintained with regards to this choice. The home has place suitable adaptations and equipment for the needs of those people living within the home. The kitchen was reasonably well maintained, but there were some work surfaces and edging to the units that needed attention – a recommendation is being made with regards to this. The owner stated that there were new fridges and freezers on order that would be more appropriate for the use of the home. The laundry area is situated in an outside building that is currently being refurbished so that the floors and walls are fully impermeable and a new industrial strength washing machine has just been purchased. Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Service users can be confident that their care and support needs are met by competent and experienced members of staff, who are aware of their needs and respect their preferences and choices. The home needs to ensure that staffing levels are appropriate in order to fully support the service users living in the home. EVIDENCE: There are currently six members of staff working within the home including the owner / manager and deputy manager. They are currently in the process of renegotiating the needs of the service users with Care Management in order to be able to recruit at least two more members of staff. In the interim they are accessing an Agency and using two regular members of staff from this Agency to support the service users in the home. Although the requirement made at the previous inspection, therefore remains outstanding – the home is managing its’ staffing levels to meet the needs of the service users. The home demonstrated that they are committed to ensuring that staff are trained appropriately in meeting the needs of those people living within the home. Staff have either undertaken most mandatory training needs or are Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 19 booked in for these courses including POVA, Food Hygiene, Manual Handling, Health & Safety, Risk Assessment, Infection Control and Medication Training. The owner / manager has recently purchased some training videos and programmes and was in the process of assessing as to whether they would be beneficial for staff and provide appropriate training – at the time of the site visit a decision was yet to be made with regards to these. One member of staff is being specifically trained in the new fire risk assessment process in order that they will have a designated fire risk assessment officer and there are plans to ensure that another member of staff is trained in food safety legislation. NVQ’s are also being promoted and 50 of staff had achieved an NVQ. The owner / manager, deputy manager and a member of staff spoken to all demonstrated an awareness of individual service users needs and it was evident during the visit that there was a good rapport between staff and service users and the interaction was friendly and supportive. Service users were confident with speaking to staff and asking advice or for any assistance. There is a through recruitment procedure in place that includes an application form, interview process, with records kept, two references are applied for and at least one is followed up with a phone call to confirm authenticity. Staff are issued with job descriptions, terms and conditions and The General Social care Councils code of conduct booklet. The home also maintains strong link with the local Care Homes Association in order to ensure that they stay up to date with good practice. New staff are not confirmed in post until an appropriate POVA and CRB check are confirmed. There is an induction programme in place, although the owner / manager is currently looking at improving this and taking into account the Skills for Care model of induction programme. The home is continually looking at ways of improving their training and induction programmes in order to ensure that staff can meet the needs of the service users. The deputy manager has recently completed her NVQ assessor’s award and intends to put this to use in supporting staff with their needs. Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42. Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Service users benefit from living in a well run home that is clearly committed to safeguarding and promoting individuals independence, rights and choices. Service users health and safety is protected by the home’s proactive approach to new legislation. EVIDENCE: The home is managed by the owner, who is registered with NMC (Nursing & Midwifery Council) as a registered nurse (RNM & RNMH). He also completed his Registered Managers Award. The Deputy Manager has also undertaken her NVQ level 4. The visit to the home evidenced that the service is managed in an open and transparent manner and that the manager and staff are approachable and well liked by the residents. The owner / manager and deputy manager were Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 21 continually exploring ways of improving their processes and ensuring that they met standards and regulations. The manager works in partnership with staff, service users and their families. There was a good awareness demonstrated by the manager and staff in ensuring that they took into account that positive outcomes were being promoted in the home, and they demonstrated that the diversity of the individuals was a high priority. They have recently introduced a new quality assurance questionnaire for service users that has been implemented by the Deputy Manager and is in a user-friendly format. It is aimed at ensuring that the home can meet the needs of the service users and also looks at how they can meet any future aspirations and goals. The pre-inspection questionnaire contained a declaration relating to maintenance and associated records. The home has a file containing documentation relating to safety and maintenance standards. The systems and procedures of the home place a high emphasis on safety within the premises and in ensuring that service users are safe at all times outside the premises subject to recorded and reviewed risk assessments. The home is pro-active at ensuring that new safety procedures and guidelines are adhered to and have implemented a robust and thorough fire risk assessment in order to ensure that they can meet the new fire regulations relating to care homes. They are also ensuring that they keep up to date with any other health and safety measures. Overall this is a well run home that is committed to supporting service users and ensuring that their health and safety is maintained. Windmill Lodge DS0000059514.V306017.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 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 X 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 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 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 2 X 3 4 3 X X 3 X Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes – although the home has maintained temporary arrangements to address this. 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 YA33 Regulation 18 (1) (a) Requirement The registered person shall..ensure that..suitably qualified, competent persons are working at the care home in such numbers as are appropriate... The required numbers of support staff should be available for the purpose of providing agreed levels of care and preparing realistic staffing rosters. This has been met in part but the home must ensure that their staffing levels are appropriate. Timescale for action 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations It is a good practice recommendation that the home DS0000059514.V306017.R01.S.doc Version 5.2 Page 24 Windmill Lodge 2. 3 4 YA9 YA20 YA17 5 6 YA20 YA24 obtains copies of care management reviews in order to promote continuity of care for service users. It is recommended that risk assessments are reviewed on a more regular basis and records reflect the date of review and changes made. It is a good practice recommendation that the home ensures that bottles and boxes of tablets are dated as to when opened. It is a strongly recommended that in order to promote good food hygiene that when jars and bottles etc are opened the date of opening is marked and that foodstuffs that need to be refrigerated on opening are stored in the fridge. It is strongly recommended that medication that is due to be returned to the pharmacist is kept separate from those medications still in current use. It is strongly recommended that the work surfaces and edging on the kitchen units are made good. Windmill Lodge DS0000059514.V306017.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Windmill Lodge DS0000059514.V306017.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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