Inspection on 21/01/06 for Windsor Drive ( 115) (117) (119)

This inspection was carried out on 21st January 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Windsor Drive ( 115) (117) (119) 16/11/09

Windsor Drive ( 115) (117) (119) 04/10/07

Windsor Drive ( 115) (117) (119) 28/09/05

Windsor Drive ( 115) (117) (119) 04/01/05

Windsor Drive ( 115) (117) (119) 05/07/04

Similar services:

Ashlea Mews Residential Home

Eastwood

West Lodge

Arran House

Avenue Community Nursing Home

Cosin Lodge

Farmborough Court

Cragston Court

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

CARE HOME ADULTS 18-65 Windsor Drive, 115/117/119 Howdon Wallsend Tyne And Wear NE28 0NX Lead Inspector Deborah Haugh Unannounced Inspection 21st January 2006 10:00 Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 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 Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 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. Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Windsor Drive, 115/117/119 Address Howdon Wallsend Tyne And Wear NE28 0NX 0191 2951004 0191 295 1080 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) www.c-i-c.co.uk. Community Integrated Care Ms Lesley Ruth Baugh Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12) of places Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th September 2005 Brief Description of the Service: Windsor Drive is a care home with nursing providing care for 12 adults with enduring mental health problems. The home is comprised of three bungalows each of which has four bedrooms with dining room/kitchen, lounge and sun room facilities, one of the bungalows has two flats which have their own kitchen and bathroom and toilet facilities. Care in the home is provided by Registered Mental Nurses supported by care staff, the home is managed and operated by Community Integrated Care, which is a national organisation providing care for a variety of client groups. The home is situated in Howden, which is in North Tyneside approximately four miles to the east of the city of Newcastle upon Tyne. The philosophy of care in the home is to support the service users in their activities of daily living and to encourage their use of local community facilities. Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on 21/01/06 at 10 am at the weekend. At the time of this inspection Lesley Baugh, the Registered Manager was on duty. There were 11 service users at the time of the visit and staffing levels were checked. Time was spent looking around the home to check the maintenance and decoration. Service users shared their views about the home. Time was also spent observing the contact between service users and staff. Care planning arrangements were examined. Arrangements for the dispensing of medication, staff recruitment, Statement of Purpose and Service User Guide, protection and requirements made at the last inspection were checked. What the service does well: What has improved since the last inspection? The office is more organised and an indexing system introduced. The Statement of Purpose and Service User Guide has been updated. Improvements to the home are underway such as new chairs, decorating corridors and the replacement of carpets. New privacy curtains have been ordered for those people who want them. Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 6 Staff are receiving training in psychosocial intervention assessment through the Scott Clinic in Liverpool. The home has exceeded the minimum standard for NVQ Level 2 training for staff (50 at NVQ Level 2 by 2005) at 100 of staff employed. The Registered Manager has completed the Registered Managers Qualification and is awaiting her result. 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. Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 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 Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 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): 1 & 5 (NMS 2 was assessed and met at the last inspection) The Statement of Purpose and Service user Guide reflects the service provided in the home. Contracts between service users, the home and placing authorities are in place, which explain service users rights and responsibilities of the home. EVIDENCE: An updated Statement of Purpose and Service User Guide is in place and the Manager agreed to send CSCI a copy of each. Individual contracts are on each service users file and provided to each person. Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 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 (NMS 7 & 9 were assessed and met at the last inspection) The care planning arrangements ensure that service users needs and wishes are addressed but some areas must be addressed. EVIDENCE: 6) Two care plans were examined and found to look at a range of needs. The assessment process is being reviewed; psychosocial intervention assessment through the Scott Clinic in Liverpool is to be introduced. Monitoring systems must improve. Evaluation timescales are not followed and dates and the key workers name on evaluations is not recorded consistently. Risk assessments are not up to date, dated or reviewed. These included fire risk and moving and handling. There is evidence of service users being consulted about their care plans. Service users photographs are required to be placed on files. Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 15, 16 & 17 (NMS 12 was assessed and met at the last inspection.) Service users have positive community presence Service users maintain relationships with family and friends. Service users rights are respected. Service users are provided with a nutritious, balanced and varied diet that meets their nutritional requirements. EVIDENCE: 13) Service users said that they are able to go out to local areas to shop, go to cafes, the local pub and surrounding facilities. Ordinary transport such as buses and taxis are used. Care plans identify specific activities and plans. 15) Service users are encouraged to see their own friends and family. One service user was away visiting family on the weekend of the visit. People spoke of their family and friends. Visitors are welcome in the home. Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 11 16) Service users routines are centred on their needs and wishes. At times people need encouragement and support to engage in activities, household routines and identified goals in care plans. 17) The catering arrangements are identified for each service user. Staff provide support where required. Menu and temperature checks are in place in each of the bungalows. In The Lodge staff were planning new menus to take into account peoples vegetarian preferences. One service user is following a healthy diet, making homemade soup and salads. Another person is receiving build-up drinks which staff were seen to encourage. Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Service users are supported in a way that meets their needs. Service users health is promoted and monitored. The systems for the storage, handling and administration of medication protect service users. EVIDENCE: 18) Service users are supported to be as independent as possible. Some people explained that they do their own shopping, cooking and look after themselves with staff support if required. Monitoring systems are in place to support people. 19) Care plans examined show that the physical and emotional needs of service users are met. Nutritional assessments are now in place. 20) Medication administration procedures were checked at the last inspection and were satisfactory in the home. However there is no counter upon which to dispense medication. Medicines are dispensed from cupboards, which also house vacuum cleaners and other items. The homes handy man is planning to provide a shelving system, which should improve dispensing arrangements. Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 13 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): 23 (NMS 23 was assessed and met at the last inspection.) Systems are in place to protect service users but all staff must receive training. EVIDENCE: 23) The Registered Manager is familiar with North Tyneside Protection of Vulnerable Adults (POVA) Procedures and has a copy of the Department of Health ‘No Secrets.’ CIC have protection procedures which link into the above. The Registered Manager has received training in POVA and 3 RMN’s. Two RMN’s and support workers staff have not completed POVA training. The finances of service users are protected by robust systems. The Community Mental Health Team Financial Assertive Outreach Team provide advice and protection to service users with the home. Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 14 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): 24 (NMS 30 was assessed and met at the last inspection) Service users live in a homely comfortable and safe environment. EVIDENCE: 24) The three premises were inspected and found to be nicely decorated and homely. The bedrooms of some service users were seen with permission and found to be personalised and comfortable. Service users said they liked their accommodation and location to amenities. Requirements made at the last inspection have been dealt with or are to be addressed by end of March 2006. The entrance corridors to some of the bungalows are due to be decorated as the wallpaper is peeling off the walls in corridors. The internal doors in all three bungalows are marked and must be re-painted. Privacy curtains have been ordered for those service users bedrooms that want them. Some of the lounge, corridor and a bedroom carpet are marked and are to be replaced. There are also some chairs with marked arms, which are also to be replaced by March 2006. Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 15 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 (NMS 35 was assessed and met at the last inspection.) Staffing numbers are appropriate to the assessed needs of the service users, size, layout and purpose of the home, at all times. Service users are cared for by staff that are trained and competent. Recruitment arrangements must be robust and protect service users. EVIDENCE: 32) The home is staffed by qualified nurses, (RMN’s). Through the day and night there is always a qualified nurse (RMN) on duty. Four support workers in the morning and 3 in the afternoon and evening. There is a sleep in support worker and an RMN awake each night. Staff retention and use of agency staff has been a problem but CIC have increased pay and morale has improved through team building. At present there are 2 full time support worker vacancies and one 16-hour post. A RMN post is vacant. The two activity co-ordinator posts have reduced to one post, which is about to be filled pending references. On the day of the inspection there were two Agency staff working who are familiar with the home. 33) The home has 100 of staff with at least NVQ Level 2. The National Minimum Standard is 50 by 2005 so the home has exceeded this. There are Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 16 five 5 RMN’s, one support worker with NVQ 3 and two with level 2. Two staff have BTEC Higher National Diplomas in Care (equivalent to NVQ Level 3). These qualifications were checked with Edexel and QCA. Staff spoke of the training which they have received which includes mandatory training. Not all staff have had training in Protection of Vulnerable Adults.(See NMS 23) 34) The Registered Manager described the recruitment arrangements for CIC with regards Windsor Drive. Appropriate checks are made and references checked. The records could not examined as Ms Baugh did not have keys to access staff records at the time of the inspection but these will be checked at the next visit. Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The Manager provides clear leadership, which ensures that the home is well run and the staff team are fully aware of their roles and responsibilities. Quality Assurance systems ensure that the service meets the needs of the service users. Health and safety arrangements protect service users but one area requires addressing. Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 18 EVIDENCE: 37) The Registered Manager is a qualified mental health nurse (RMN) and has completed and awaiting verification of the Registered Managers Qualification. Ms Baugh has agreed to send a copy of her qualification when obtained to CSCI. 39) The office has been re-organised and indexed and further improvements are to be made. This now enables RMN’s who act as assistant home managers easy access to information when the manager is not on duty. 42) The safety procedures in the home were examined and found to be generally good. A tour of the premises found no hazards. Staff security at night has been examined and steps taken with further discussions to take place. However the following health and safety matter must be addressed; - Provide CSCI with proof that portable electric equipment is safe. (Previous Portable Appliance Test was completed 04/04) Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 23(2) Requirement The following health and safety matter must be addressed; 1. Provide CSCI with proof that portable electric equipment is safe. (Previous Portable Appliance Test was completed 04/04 Staff must receive training in the Protection of Vulnerable Adults Care plans must be 1. Evaluated at identified timescales, dated, and updated. 2. Authors of documents must sign and date. 3. Risk assessments must be reviewed, updated and dated. 4. Service users photographs must be on their records. The following area must be addressed. 1. Re-paint internal doors in all three bungalows. Timescale for action 31/03/06 2. 3. YA23 YA6 18 15 and schedule 3 31/03/06 31/01/06 4. YA24 23 (2) (d) 31/03/06 Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 21 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 YA20 YA37 Good Practice Recommendations Review medication dispensing and storage arrangements. Provide CSCI with Registered Managers Qualification certificate Windsor Drive, 115/117/119 DS0000000364.V276238.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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. 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