Inspection on 05/11/05 for Windmill Lodge

This inspection was carried out on 5th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Lodge 09/11/06

Windmill Lodge 18/05/06

Windmill Lodge 09/06/05

Windmill Lodge 13/10/04

Windmill Lodge 05/05/04

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Windmill Lodge 115 Lyham Road London SW2 5PY Lead Inspector Pam Cohen Unannounced Inspection 5/11/05 7.30am & 9/11/05 9.30 am 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 Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Windmill Lodge Address 115 Lyham Road London SW2 5PY 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) 0208 674 4940 Excelcare Holdings Ms Grace Ebun Ale-Olurin Care Home 93 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The home must appoint a Deputy Care Manager There must be team leaders on every floor. Respite care must be limited to 4 beds on the ground floor and four beds on the first floor. Intermediate care must be restricted to the third floor and no other form of care may be provided on that floor. There must be a minimum of two nurses on shift on each of the first and second floors during the waking day. Date of last inspection 9th June 2005 Brief Description of the Service: Windmill Lodge is a newly built care home which was opened in January 2004 and looks after 93 people on 4 floors. The ground floor offers residential care for 21 older people; the other floors offer nursing care. There are 4 respite beds on the ground floor and 4 on the first floor. All rooms have an en-suite toilet and shower. There is a courtyard garden and a small amount of parking to the front of the building. The home is next to a small general store. It is not on a bus route but is near Brixton, Streatham and Clapham all of which have good transport links. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors spent the day of 5/11/2005 at the home. They inspected the building and documentation and had the opportunity to speak to service users, relatives and staff. One inspector went back on 9/11/2005 and spent the morning with the manager discussing management systems within the home. In between the two days of the inspection Excelcare produced an action plan to address some of the issues found on the first day of inspection. What the service does well: 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. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 6 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 Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4,5. There is no intermediate care offered at the home. The home is not yet able to demonstrate that it is meeting the assessed needs of the service users. Contracts do not relate to individual service users. Relatives are enabled to visit the home to check on its suitability. EVIDENCE: Although contracts were attached to the service users’ files that were seen, these had not been filled out for the individual nor had they been signed. It was therefore not clear whether they had been seen by service users or their relatives. Those asked could not remember seeing a contract. From evidence seen during this inspection the home is not meeting the assessed needs of service users. Service users suffering from dementia are not offered a service appropriate to their needs and the cultural needs of service users are not assessed. There are also not staff in sufficient numbers and with sufficient training to look after the needs of the service users. These matters are detailed further under the relevant standards. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 8 Most service users are admitted to the home from hospital and had not had the opportunity to visit but all confirmed that if they had not visited, their relatives had. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,11, Care planning is poor with the result that service users’ care and health needs are not fully assessed or met. Medication administration was found to be improperly documented and service users are not always getting the medication prescribed. The manager described good practise for dealing with death and dying. EVIDENCE: The inspectors looked at ten care plans. They found that they did not set out service users’ care and health needs to an acceptable standard, they also did not give evidence to show that these needs had been met. Needs assessed before admission were not recorded in the care plan. Personal care needed was not detailed. There was little or no information on service users’ psychological or mental health needs. Service users who clearly suffered from a degree of dementia had no recording of the impact this was having on their behaviour, or how best to help them. Similarly service users who exhibited some challenging behaviour had not had risk assessments that could help minimise risk to them and their carers. There was little or no information on service users’ social or cultural needs, their likes and dislikes concerning the way they were looked after, the food they liked and the way they liked to spend the day. There were no life histories on the files. One service user had Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 10 been in the home for ten days and there was no care plan yet. Two care plans were seen that did contain a statement that they had been drawn up with a relative but this was not wide spread as yet and it was not clear whether the service users themselves had been involved. Reviews seemed to be written by rote, as changes noted in the daily notes were not evidenced in the reviews which simply said “as before.” Risk assessments were not individualised and usually just addressed the risk of falls. Not all service users who used bed rails had had a risk assessment to ensure that this was a safe practise. Health issues were often not well dealt with. Reports with information from doctors did not have this information transferred to the care plan in order to be dealt with. An important assessment by a speech and language therapist, designed to prevent the risk of a service user choking, was similarly not transferred to the care plan and was not being adhered to. A service user on a PEG feed did not have up-to-date fluid charts and generally when fluid charts, or nutritional charts were filled in, they were sketchy and there was no evidence that they were evaluated or that information gathered had been used in any way. A service user was seen by the GP because of lack of appetite and loss of weight but these conditions were not monitored or reviewed. The manager told the inspectors that work was underway to improve care plans. A few of the care plans had some areas that showed that this was happening, with good assessments of what care was needed and how it should be delivered. However in the files seen these were the exception and not the rule. In the home there was no evidence of risk assessments to see if people can self medicate. Especially on the residential floor every effort should be made to ensure that service users are able to be as independent as possible. Medications checked did not agree with medication administration charts. It seemed that charts had been signed when the medication had not always been administered. The commission’s pharmacy inspector will be following this up. The inspector discussed the way that the home deals with death and dying with the manager. There is a policy which is followed which aims to ensure that support is given as needed to the service user and their family. The home aims to liaise closely with professionals such as the Palliative care team and Macmillan nurses and every effort is made to enable the service user to die in the home, if that is their wish. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14. Despite the work of the activities organiser there is not sufficient suitable activities for service users in the home, leading to under stimulation. Service user autonomy would be improved if every effort were made to assess if they were able to deal with their own finances. EVIDENCE: The inspector spoke to the activities organiser and was impressed by her commitment to the job and the efforts she makes to provide activities both on a group and individual basis. However hers is one 30 hour post and there are 93 service users with differing wishes, capabilities and needs. The limited amount of hours available to the organiser plus the heavy work load of care staff means that most service users spend most of the time without the possibility of a stimulating activity. This is particularly marked at the weekend. The inspectors visited on a Saturday and saw no evidence of any activity of any kind for the service users. The activities programme shows only 2 hours of planned activity diaried for the 4 Saturdays in the month. A relative was concerned that her mother was isolated and not receiving enough stimulation and a service user said that “I mostly read and fall asleep”. The activities organiser has started to produce very good care planning for service users Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 12 social life; this needs to continue and to be supplemented by care planning to meet service users’ cultural and religious needs. Service users are able to bring in personal furniture and possessions if they wish. Advice about Age Concern’s advocacy service is included in the service users’ guide. However no service users deal with their own finances and were not even signing for their own personal allowance when it arrived. Every effort should be made to maximise service users’ independence and on admission a service user’s capability to deal with all or some of their own financial affairs should be assessed. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. Due to poor investigation of complaints, service users and their relatives cannot be sure that their complaints are taken seriously or the issues they raise, dealt with. Service users cannot be sure that they are protected from abuse due to management response to allegations of abuse, inadequate training and checking of staff that is not in line with requirements. EVIDENCE: The response to complaints continues to be poor. The home has a satisfactory policy and procedures and complaints are logged. However the complaints are not then dealt with effectively. The commission has received letters from relatives who are not satisfied with the way their complaints have been dealt with. During the inspection the inspector went through some complaints with the manager and noted that investigation had not been thorough and not all issues properly dealt with. Since the last inspection there have been several allegations which have necessitated the involvement of the local authority vulnerable adults team because they included allegations of abuse. The most recent involves issues of abuse and restraint. It is of considerable concern that this most recent allegation was not promptly reported to the Vulnerable Adults team or to the CSCI and that the named staff were not dealt with in any way or their names placed on the temporary POVA list. Training records showed that only about 25 of staff have attended vulnerable adults training in the past 12 months. Staff recruited have also not been subject to an enhanced CRB check as is required, but only to a standard one. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 14 Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26. The standard of the environment is good and means that service users have an attractive and comfortable home. The standard of cleanliness and hygiene is also good. EVIDENCE: The home is purpose built and was seen to be generally well maintained, suitable for its purpose and safe. There are a number of communal rooms on the building. Each floor has a large living room and dining room and in addition there are small seating areas in the corridor, a prayer room and smoking areas. There is a pleasant enclosed courtyard garden. All bedrooms are of sufficient size and well decorated. They have en-suite toilets, washing and shower facilities. In addition there are assisted bathing facilities on each floor. Service users can bring their own possessions in, subject to space and safety checks and all rooms were seen to have appropriate furniture. It was noted that temperatures in the home seemed very high. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 16 On the day of the inspection the home was clean throughout and service users and relatives commented that this was always the case. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Service users cannot always be sure of receiving the care they need due to levels of staffing. Some recruitment practices to not fully ensure service user safety. Poor standards of training mean that staff may not be competent to do their job safely and well. EVIDENCE: Staffing levels on the day of inspection did not meet the agreed staffing levels or the additional condition of registration that there must be a minimum of 2 RGNs on the 2nd floor during the day. The understanding of the staff was seen to be that agency staff should not be used to cover vacancies. The manager said that this was not true, but nevertheless the vacancies on shift had not been filled. The inspectors were of the opinion that even when fully staffed, the rota did not have enough cover in relation to the needs of the service users on the first and second floors. Staff were fully occupied in dealing with the immediate care needs of the service users and this meant they had no time to speak to service users or find appropriate activity for them. It also meant that most of the time there was no member of staff in the lounge to ensure the safety of the service users there. Files of recently recruited care, nursing and domestic staff were seen. Much documentation was complete, however there were gaps in employment histories where there should be none. Also although there were two references on each file, these were in one instance, both for from one place of work. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 18 References were on the whole from colleagues and not from managers and therefore they cannot be deemed suitable. It was also noted that CRB checks were standard and not enhanced. The home is making good progress in reaching the target of 50 of care staff trained to NVQ level 2 or equivalent. However other aspects of training that would ensure that service users needs are being met were not in place. There is no training and development plan for the staff as a whole, nor are there individual training plans. There is also no system for the manager to see what training has been provided to staff on a year to year basis although the manager is in the process of drawing up a matrix for this. This is essential as it is became clear when checking through training delivered in the past year, that many staff have not received the training that they need to do the job. Staff members are not receiving induction and foundation training to NTO specification and most are not receiving a minimum of 3 paid days training a year. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38. Some health and safety practices leave service users at risk EVIDENCE: On the day of inspection there were several areas of concern regarding Health and Safety within the home. The front door was left “on the latch” all morning which has safety implications. Doors to service users’ rooms were held open with a variety of implements at night and during the day. This has serious implications in the event of a fire. Staff training records showed that training in essential areas of Health and Safety was not happening to a sufficient degree. These areas included moving and handling, first aid, food hygiene and infection control. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 20 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 2 x 2 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x x x x x x 2 Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? YES 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 OP2 Regulation 5(1)(b) Timescale for action The registered person must 31/12/05 ensure that each service user is provided with statement of terms and conditions pertaining to their admission to the home. This should be signed. The registered person must 31/01/06 ensure that service users’ cultural needs are assessed and met; that service users suffering from dementia have their needs assessed and met, and that staff are deployed in sufficient numbers and with suitable training . The registered person must 31/01/05 ensure that care plans are kept up-to-date and contain clear guidance to staff on the actions to be taken to meet their health care needs. Professional guidance must be incorporated into care plans and followed. All changes must be documented and reflected in the care plans. Previous timescale of 30/09/05 not met The registered person must 31/01/06 ensure that the care plans DS0000058177.V252494.R01.S.doc Version 5.0 Page 22 Requirement 2 OP4 12(1)4(b) 18(1)(a) 3 OP7OP8 15(1) 4 OP7 15(1) Windmill Lodge 5 OP8 13(1)(b) 6 OP9 13(2) 7 OP9 12(2) 8 OP12 16(2)(m)( n) 12(4)(b) 9 OP16 22(3)(4) 10 OP18 12(1)(a) 11 OP18 13(6) 12 OP18 19(4)(c) include assessment of service users’ social and emotional needs as well as their physical well being and that the plan is drawn up with the involvement of the service user, where possible. The registered person must ensure that service users’ psychological health is assessed and needs met. The registered person must ensure that all medication signed for as given to a service user, has been given. The registered person must ensure that every effort has been made to ensure that the service users are able to self medicate if they wish to do so and it is safe. The registered person must ensure that service users’ interests are recorded and capabilities assessed in order to ensure that all service users are given appropriate stimulating activities. Particular consideration must be given to people with dementia and to people with a physical or sensory disability. The registered person must review how they deal with and respond to complaints. Previous timescale of 30/09/05 not met The registered person must ensure that all allegations of abuse are dealt with promptly, including passing on the allegations to the relevant bodies. The registered person must ensure that all staff receive training in dealing with vulnerable adults and abuse. The registered person must DS0000058177.V252494.R01.S.doc 31/01/06 31/12/05 31/12/05 28/02/06 31/12/05 30/11/05 31/03/06 31/03/06 Page 23 Windmill Lodge Version 5.0 13 OP27 18(1)(a) 14 OP29 12(1)(a) 19(1)(c) 15 OP30 18(c)(i) 16 OP38 23(4) 17 OP38 13(5) ensure that all staff have an enhanced CRB check The registered person must ensure that there are sufficient staff on duty to comply with conditions of registration and to meet the assessed needs of service users. The registered person must ensure that there is a full history of employment for all staff on recruitment. Also that references are guaranteed to be as authentic as possible by being from managers and not colleagues of the staff concerned. The registered person must ensure that persons employed at the home receive training appropriate to the work they perform with particular regard to nursing and personal care. Previous timescale of 30/09/05 not met The registered person must ensure that fire service advice is sought and followed regarding the practice of wedging service users’ doors open, especially at night. If advised against this practice the appropriate equipment must be bought The registered person must ensure that an audit is done of all staff’s moving and handling training. All training needs to conform to the required standard and be updated annually 31/12/05 31/12/05 31/05/06 05/12/05 12/11/05 Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 24 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 OP25 Good Practice Recommendations It is recommended that the registered person monitor the temperature in all parts of the home to ensure that it is not too high. Windmill Lodge DS0000058177.V252494.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 DS0000058177.V252494.R01.S.doc Version 5.0 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. 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. 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