Inspection on 09/11/06 for Windmill Lodge

This inspection was carried out on 9th November 2006.

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 18/05/06

Windmill Lodge 05/11/05

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 Lisa Wilde Unannounced Inspection 11:00 9 , 10 & 20 November 2006 th th th 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.V319721.R03.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 Lodge DS0000058177.V319721.R03.S.doc Version 5.2 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 0208 674 5466 grace.ale-olurin@excelcareholdings.com Windmill Healthcare Ltd Ms Grace Ebun Ale-Olurin Care Home 93 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0), Physical disability of places over 65 years of age (0) Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. There must be team leaders on every floor. Respite care must be limited to 4 beds on the ground floor and 4 beds on the first floor. Intermediate care must be restricted to the third floor only There must be a minimum of two nurses on shift on each of the first and second floors during the waking day and a minimum of one nurse on the third floor on each shift during the waking day. 18th May 2006 Date of last inspection Brief Description of the Service: Windmill Lodge Care Centre is a modern, purpose built care home run by Excelcare for 93 older people in Brixton. There are four floors with the ground floor offering residential care and the other three floors offering nursing care. There are eight respite beds in the home, which are limited to four respite beds on the ground floor and four respite beds on the first floor. There is a general store next to the home and Brixton shopping centre and station is a short drive one way from the home and about the same distance in the other direction is Streatham Hill shopping centre and station. The service user guide states the current range of fees is £340 per week for residential care, £497.12 for nursing care and £520 for frail elderly nursing care. Additional charges are made for things such as hairdressing and newspapers. The provider makes copies of the reports of the Commission’s inspections available in the reception area. Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days in October 2006 with an additional day spent telephoning relatives of service users. The Registered Manager was on annual leave at the time of this inspection. The inspector met with the Care Manager, who is in charge when the Registered Manager is on leave, staff and service users. The inspector toured the building, examined records and checked medication stocks. The service users who the inspector spoke with said that they were happy at the home and that things had improved over the past year or so. Most of the relatives who the inspector spoke to were happy with the home although some were less happy. Some relatives talked about how their service users had put on weight, looked better and were a lot healthier than before they moved to the home. Some relatives said things like “We’re so lucky to have our mother in this place” and how the home was “Marvellous”. Other relatives were less enthusiastic but still said that the home was “alright” and “could be a lot worse”. Some relatives had concerns about there not being enough staff or staff not talking to service users when they moved them or helped them with personal care. (The issue of staffing is discussed under Standard 27 in the main body of this report). It is clear that this is an improving service. There are several areas that still need working on but the Care Manager was aware of most of those areas and talked about plans to make things better. What the service does well: • • • • • • Senior staff assesses prospective service users’ needs before they move to the home. Family and friends can visit as they choose. The home has adequate living and dining areas on each floor. Service users have their own en-suite rooms which are large enough and which they can decorate as they choose. Service users have the specialist equipment they need to live safely in the home. The home is clean and hygienic throughout. DS0000058177.V319721.R03.S.doc Version 5.2 Page 6 Windmill Lodge • • • • Service users are listened to and their concerns are taken seriously and acted upon. Service users are protected from abuse. The required number of staff hold or are undertaking the NVQ Level 2 in Care. Staff receive adequate training in order for them to be able to meet the needs of service users. What has improved since the last inspection? What they could do better: • • • • • • • • • All areas of care plans must be reviewed regularly. Service users must get enough exercise (or the exercise must be recorded properly). The home must offer effective end of life care that follows current best practice. Service users’ individual needs regarding stimulation and fulfilment must be met. Medication systems and procedures must be followed effectively. Individual staff training needs must be assessed annually. Staff must be able to communicate effectively with service users. Recruitment procedures must be improved in some areas. The home must show that it is planning each year to improve all areas of the service in ways that service users and their relatives want. Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 7 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 DS0000058177.V319721.R03.S.doc Version 5.2 Page 8 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.V319721.R03.S.doc Version 5.2 Page 9 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): 2&3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are issued with terms and conditions that tell them about their rights and responsibilities so they know what is expected of them and what they can expect from the home. Not all the details of these contracts are filled in which means that service users are not given all the information they need. Senior staff assess prospective service users’ needs before they move to the home so that no one is offered a place without the staff team believing they can support someone. EVIDENCE: There is new legislation in place now that came into force on 01/09/06 and other changes come into force on 01/10/06 which will require services to state exactly what fees each service user is paying and how it breaks down into different areas. (See Requirement 1) Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 10 The service user or their representative has now signed most of the terms and conditions for service users. Of the files examined some terms and conditions had not been signed by the provider, some did not include fees or rooms numbers and none stated whether the terms and conditions were privately funded or funded by the local authority. (See Requirement 2 & Recommendation 1) All files examined included an assessment of service users’ needs conducted prior to them moving to the home. Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 11 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 & 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are in place that state what staff will do to support service users in all aspects of their life. Staff follow these care plans and most areas of the plans are reviewed every month with service users and their family so that service users know that their changing needs are met. Risk assessments are not all reviewed monthly which means that certain elements of risky behaviour may not always be effectively managed. Details of health care monitoring are recorded in the service user files and accurate notes kept of any day-to-day issues. Service users do not get enough exercise (or the exercise is not being recorded properly) so the home is not showing that it is meeting service user needs in this area. Medication stocks do not always tally with the medication records which means that staff are not following medication procedures effectively. Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 12 Service users are treated with respect and their privacy is maintained. Service users are cared for when they are dying but as care is not being offered according to current best practice and the home may not be doing all it can to effectively offer the most effective end of life care. EVIDENCE: There was a previous requirement that the registered person must ensure that care plans include the assessment of service users’ social and emotional needs as well as their physical wellbeing. The care plan should be drawn up with the involvement of the service user, where possible. A lot of work has been done on care planning in the past few months and all service files examined by the inspector included assessments of all service users’ needs. Most of the care plans had been signed by the service user or their representative. Letters had been sent to those relative show had not yet signed the care plans, asking them to attend and do so. Some service users do not have relatives to sign care plans or contracts and the home’s service user guide states that the home will access local advocacy groups. The care manager said that the home has not yet done this. (See Requirement 3) There was a previous requirement that the registered person must ensure that care and health needs are reflected accurately in care plans and are kept upto-date. Professional guidance must be incorporated into care plans and followed. Files showed that this is now being done. There was a previous requirement that the staff were to receive training in supporting service users with swallowing difficulties, communicating with service users who have a hearing impairment and palliative care. Training has been done around swallowing and working with people with hearing difficulties for a number of staff. The issue about palliative care training is discussed further later in this section. The majority of care plans are reviewed monthly as required but the risk assessments are not reviewed as regularly. (See Requirement 4) Although most files included evidence of annual reviews of the care plan, no files included a six-weekly review of care when someone first moves to the home (as required by the organisation’s policy). (See Requirement 5) There were some care plans that stated that service users should be supported to exercise regularly but daily records showed that this is not necessarily being done regularly as required. (See Requirement 6) Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 13 The inspector saw staff talking to each other in language that was not English, in the presence of service users. (See Requirement 7) There was a previous requirement that the registered person must ensure that all residents are given the opportunity and support to self-administer their medication unless they have been risk assessed as not being able to. Medication risk assessments are on file but they do not include discussion about why the service user is not self-medicating, just statements saying that they cannot do so. (See Requirement 8) The inspector checked the medication stocks and records on all floors and found several medications that did not tally with the records. (See Requirement 9) There was a previous requirement that the registered person must ensure that the incidence of urinary tract infections is investigated, that fluid intake is adequate and that infection control procedures are being followed. Fluid charts show that fluid intake is being monitored. There was a previous requirement that the registered person must ensure that both the monitoring device and the lancing device currently being used for blood glucose monitoring are suitable for multiple patient use. There are now separate lancing devices for all service users who need them. There was a previous recommendation that the registered person should ensure that fluid charts are kept with the service user or in the service users rooms to prompt and enable easy access by staff and relatives to fill them in after they have assisted the service user to take any fluids. This is now being done. There was a previous recommendation that the registered person should ensure that records of important and essential information relating to individuals’ conditions sent with service user when they attend hospitals. There is a now a form that goes with the service user to hospital. There was a previous recommendation that the registered person should ensure that when referrals are made to healthcare professionals that delays in response to these referrals are followed up. Files showed that referrals are followed up. There was a previous recommendation that the registered person should ensure that homely remedies are used for residents only and alternative arrangements are made if the home wishes to provide treatment for minor ailments to staff. Homely remedies are no longer used for staff. Some files included a detailed care plan around End of Life care and some included a checklist of practical details such as whether the service user Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 14 wanted to be buried or cremated. The home is not yet operating in accordance with best practice in this area as it does not work with systems such as the Gold Standard Framework or the Liverpool Care Pathway. The home has begun to access training from the Care Home Support Team around End of Life care. (See Requirement 10) Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. The home is not yet doing enough to make sure that service users’ individual needs regarding stimulation and fulfilment are being met. The home is not yet doing enough to make sure that service users can access the local community as they choose. Family and friends can visit as they choose. Service users and their families are given information in order that they can make choices. Service users are offered a variety of different food options every day although some service users and relatives are less happy with the food than others. EVIDENCE: There was a previous requirement that the registered person must ensure that where possible, individuals’ interests and previous lifestyles are recorded on Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 16 the care plan and that appropriate stimulating activities are devised to respond to these needs. Social care assessments or Life Reviews are on file for service users that describe what they enjoy doing. There are two part-time activities co-ordinators in the home who organise a variety of group activities but who do not have the time to conduct many individual sessions with service users. Staff said and the inspector observed that there are not always enough staff on duty to take service users to the activities in the home or stay with them to support them with the activities which means that less able service users are not getting as much input around activities. The activities co-ordinators have received training, which they described as very useful. They have not received training in how to facilitate reminiscence work or how to conduct exercise with service users. (See Requirements 11 & 12 & Recommendation 2) There was a previous recommendation that the registered person should ensure that appropriate facilities and formats such as orientation boards for communication are provided to enable communication and stimulation. The care manager said that they are waiting for a trainer to send through equipment and materials. There was a previous recommendation that the registered person should ensure that staff develop the language skills to effectively communicate with service users and their families. The care manager said that this is an ongoing problem. Staff attend classes in English but it is obviously a slow process. (See Requirement 13) The home runs a four-weekly standard menu and a weekly African/Caribbean menu. During the inspection staff had to tell the chef that pureed meal should presented as separate portions of different foods and not have all elements of the meal pureed together. While this would mean that the standard was not met the Care Manager assured the inspector that he had dealt with this issue on the day and it would not be happening again. Some service users and relatives were happy with the food and some were not and the last food survey showed the same. The inspector did not find enough evidence to state that this standard wasn’t met but will further assess the issue of food at the next inspection. Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. Service users are listened to and their concerns are taken seriously and acted upon. Service users are protected from abuse by staff being trained in the issues and systems in place for the protection of service users being operated effectively. EVIDENCE: All formal and informal complaints are recorded and investigated. Managers conduct a monthly audit of complaints. Staff are trained in the protection of vulnerable adults. The home works closely with the boroughs adult protection team to make sure tat allegations are investigated appropriately. There had been no allegations since the last inspection although during this inspection one issue was raised that had to be referred to the adult protection team for investigation. Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 18 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, 20, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has adequate living and dining areas on each floor. Service users have their own en-suite rooms which are large enough and which they can decorate as they choose. Service users have the specialist equipment they need to live safely in the home. On the day of the inspection, the home was clean and hygienic throughout. EVIDENCE: Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 19 Service users have their own rooms with en-suite facilities. Service users told the inspector that they were happy with their rooms and they could bring their own belongings in to make them more homely. There is a lounge/dining room on each floor with the third floor also having a separate quiet room. The lounge/diner on the third floor is quite small. On the days of the inspection the home was clean and hygienic. Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 20 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, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There may not be enough staff on duty to meet the needs of service users, further evidence is required. The required number of staff hold or are undertaking the NVQ Level 2 in Care which means that staff know what they are doing. Staff receive adequate training in order for them to be able to meet the needs of service users although their training needs are not assessed annually which means they may not be receiving the best training to develop their practice. Recruitment procedures have improved significantly but there are still a few issues to address to make sure that effective checks are in place to make sure staff are who they say they are and can do the job they are hired to do. EVIDENCE: Evidence throughout the inspection indicated that there may not be enough staff to meet service users needs. The inspector observed one floor where nine service users were alone in the lounge while staff were attending to service users in their rooms and service users in the lounge needed to go to the toilet; staff and relatives reported that staff do not have enough time to spend quality Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 21 time with service users or that staff are too busy to speak to service users, staff said that sometimes service users needs exceed the number of staff hours available, staff and service users reported that sometimes there is not a senior member of staff on duty at night on the ground floor which means that a nurse from another floor has to leave and give medication to service users. (See Requirement 14) Currently just over 50 of staff hold or are undertaking the required NVQ in Care. The inspector examined several staff personnel files and found that generally there was a robust and consistent recruitment procedure in place apart from there only being one interviewer so staff, that POVAFirst is being used as a matter of course as opposed to just in emergency situations, that old Criminal Records Bureau (CRB) checks are not being destroyed and Equal Opportunities forms are not anonymous and are held on staff files. (See Requirements 15-17 and Recommendation 3) There is a plan for all training over the coming year that has been concentrating initially on the statutory training required. This plan has not yet been based on individual staff training and development plans drawn up following annual appraisals as the appraisals have not yet been carried out. (See Requirement 18) Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 22 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, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is not doing all it can to plan for the forthcoming year based on the views of service users and make sure that things get better in ways that they want. The financial systems in operation in the home make sure that service users’ money is held safely and they are protected from abuse. Staff are now supervised regularly and effectively, which means that service users are supported by people who receive enough support and advice from managers. Recording has improved significantly and is now effective in all areas. Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 23 Health and safety systems are operated as they should be apart from in the areas of weekly fire system tests and fire drills. EVIDENCE: The Registered Manager was on annual leave during this inspection so her abilities could not be assessed. The Care Manager (who manages the home in the Registered Manager’s absence) evidenced his awareness of the needs of service users and how the home should meet those needs. The home and organisation conducts a large amount of checking and information gathering. There is a survey of service users and relatives every six months and statistical information is produced in the form of a report. There is no plan put in place to analyse the qualitative information in those surveys and make sure that improvements are made before the next survey six months later. Although there is a business plan for the home this does not include specific information about service users views of the home and how the home will develop and improve in response to those views. (See Requirements 19 & 20) Service users’ money is protected by robust accounting procedures. The administrator holds accurate records of money held by the organisation and two staff signing for any transactions when service users cannot sign. Currently monthly statements are generated for service users but these are not yet given to service users or their relatives. (See Requirement 21) There was a previous requirement that the registered person must ensure that one to one supervision is provided to all staff at least six times a year. Files showed that staff are now regularly receiving supervision although as mentioned earlier annual appraisal of performance have not yet been carried out. Staff who offer supervision have received training in how to supervise. Some new staff have started at the home and have not received supervision for one or two months. (See Recommendation 4) All the required health and safety documentation and checks were in place and in order apart from in the area of fire system checks as there is currently a fire drill every week which is being used as a check of the fire system. This means that the fire points aren’t being checked as the drill is initiated at the main fire panel and the drills are occurring too often. (See Requirement 22) Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 2 2 X 2 Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 25 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 OP1 Regulation 4&5 Requirement The Registered Individuals must ensure that the breakdown of each service users’ fees is put these in the service user guide/statement of purpose as required by the new legislation. The Registered Individual must ensure that all parts of the service users’ terms and conditions are completed. The Registered Individuals must ensure that information is gathered about appropriate advocates for service users and they are actively used in the home as required. The Registered Manager must ensure that all elements of the care plan are reviewed monthly. The Registered Manager must ensure that six-weekly reviews of placements take place as required by organisational policy. The Registered Individual must ensure that service users exercise appropriately and as per care plans and records of this exercise are accurately maintained. Exercise must be DS0000058177.V319721.R03.S.doc Timescale for action 31/12/06 2. OP2 5 31/12/06 3. OP7 OP14 OP16 15 28/02/07 4. 5. OP7 OP7 15 15 30/11/06 30/11/06 6. OP8 OP12 16 (2) (m) 28/02/07 Windmill Lodge Version 5.2 Page 26 7. OP8 12 (1) (a) 8. OP9 13 (2) 9. 10. OP9 OP11 13 (2) 15 11. OP12 12 (1) (b) & 16 (2) (m) (n) 12. OP12 12 (1) (b) & 16 (2) (m) & (n) 12 (1) (a) 13. OP12 14. OP27 18 (1) (b) offered by appropriately trained staff. The Registered Manager must ensure that staff speak English in the presence of service users (or the first language of the service user if English is not their first language). The Registered Manager must ensure that all residents are given the opportunity and support to self-administer their medication unless they have been risk assessed as not being able to. Previous requirement: Unmet timescale 01/09/06 The Registered Manager must ensure that medication stock checking systems are effective. The Registered Individual must ensure that staff are trained in and the home operates such systems as the Gold Standard Framework and the Liverpool Care Pathway to fully support someone according to best practice when dying. The Registered Manager must ensure that appropriate stimulating group and individual activities are devised to respond to service users assessed needs. Part of previous requirement: Unmet timescale 30/08/06 The Registered Individuals must ensure that appropriate reminiscence activities are offered by effectively trained staff. The Registered Individuals must ensure that staff develop the language skills to effectively communicate with service users and their families. The Registered Individuals must ensure that an audit of care hours required by service users is carried out and compared to DS0000058177.V319721.R03.S.doc 30/11/06 30/11/06 09/11/06 28/02/07 28/02/07 28/02/07 28/02/07 31/01/07 Windmill Lodge Version 5.2 Page 27 15. OP29 16. OP29 17. OP29 18. OP30 19. OP33 20. OP33 OP36 21. OP35 the number of staff hours available. This audit must be sent through to the Commission. 13 (6) & The Registered Individuals must 17 (2) ensure that at least two appropriately trained people interview all job applicants. 13 (6) & The Registered Individuals must 17 (2) ensure that the POVAFirst check is only used in emergency situations and not to start staff as a matter of course without a CRB check. 13 (6) & The Registered Individuals must 17 (2) ensure that CRB checks are destroyed after six months or when the inspectors have had the opportunity to see them and that a central record is then maintained of the CRB date and number. 18(1)(a)(c The Registered Individuals must ) (i) & (ii) ensure that individual training and development plans are drawn up following an at least annual appraisal of staff performance and training needs. 24 The Registered Individuals must ensure that the most effective means are used for gathering service users’ and their relatives’ views on all aspects of the service. These views must be drawn up into at least annual reports (including any qualitative comments, not just results of tick box questions) and action plans put in place to improve on these areas each year. 24 The Registered Individual must ensure that there is an annual development plan based on the views of service users, their relatives and other stakeholders that shows how the home intends to improve and develop over the forthcoming year. 13 (6) The Registered Manager must DS0000058177.V319721.R03.S.doc 30/11/06 30/11/06 30/11/06 28/02/07 28/02/07 28/02/07 30/11/06 Page 28 Windmill Lodge Version 5.2 22. OP38 23 (4) (c) (v) & 23(4)(e) ensure that service users (or their relatives) who have their money managed by the organisation, are given the monthly statements of their account. The Registered Individuals must ensure that different fire call points are tested weekly as required and that fire drills do not take place too often. 09/11/06 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. 2. Refer to Standard OP2 OP12 Good Practice Recommendations The Registered Manager should ensure that records of efforts that have been made to get the service user or relative to sign the terms and conditions are kept on file. The Registered Manager should ensure that appropriate facilities and formats such as orientation boards for communication are provided to enable communication and stimulation. Previous recommendation. The Registered Individuals must ensure that Equal Opportunities forms are held anonymously. The Registered Manager should ensure that all new staff are formally supervised within the first month of starting at the home. 3. 4. OP29 OP36 Windmill Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Lodge DS0000058177.V319721.R03.S.doc Version 5.2 Page 30 - 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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