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Inspection on 28/09/05 for Windsor Drive ( 115) (117) (119)

Also see our care home review for Windsor Drive ( 115) (117) (119) for more information

This inspection was carried out on 28th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The premises are very homely and domestic in style. Residents say they feel well cared for. There are good systems in place for ensuring that the staff in the home are aware of their duties and responsibilities. Staff are pleasant and helpful and relate well to residents who are treated respectfully.

What has improved since the last inspection?

Some areas of the home have been redecorated including the provision of new kitchen units.

What the care home could do better:

The home must seek to recruit permanent support staff. The home must work towards improving morale. Some items of furniture need to be replaced. Some carpets are marked.

CARE HOME ADULTS 18-65 115/117/119 Windsor Drive Howdon Wallsend Tyne & Wear NE28 0NX Lead Inspector Aileen Beatty Unannounced 28 September 2005 11:30 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 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 Stationary 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. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 115/117/119 Windsor Drive Address Howdon Wallsend Tyne & Wear NE28 0NX 0191 295 1004 0191 295 1080 N/A Community Integrated Care Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Lesley Ruth Baugh CRH 12 Category(ies) of MD - Mental Disorder (12) registration, with number of places 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 04/01/05 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 residents in their activities of daily living and to encourage their use of local community facilities. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place at 11.30 a.m. on 28/09/05. The inspection consisted of discussions with staff and residents and a tour of the premises. Records were also checked. The inspection found that the overall standard of care is good. 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. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 7 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 standard(s) 2 and 5. Prospective service users individual aspirations and needs are assessed. Each service user has an individual written contract or statement of terms and conditions with the home. EVIDENCE: Records examined demonstrate that the individual needs of service users are assessed and they are included in all aspects of decision making about their care. Individual contracts were observed. It was noted that the Statement of purpose did not contain all of the required information. This was located in the office and may not be the most up to date version, in which case it must be discarded. The Service User Guide needs to be updated to amend NCSC to CSCI. Residents spoken to said that they feel well cared for. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 8 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 standard(s) 7 and 9. Service users make decisions about their lives and are supported to take risks as part of an independent lifestyle. EVIDENCE: Residents are encouraged to make decisions about their own lives. They are included in all aspects of care planning and in decision making about the running of the home. Residents meeting minutes were available for inspection. There are no residents with formal advocates at present but they are all seen by the manager on a regular basis to discuss any concerns they may have. One resident has a befriender. Rehabilitation plans describe how independence of each resident will be promotedified where it was felt that residents were being prevented for taking every day risks. Risk assessments are carried out in relation to certain activities and these are well documented. It is recommended that it should be recorded when a resident refuses to sign care plans or risk assessments. A service model review is currently underway looking at the possibility of working within a total rehab model. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 9 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 standard(s) 12, and 17. Service users are usually able to take part in age, peer and culturally appropriate activities. A healthy diet is offered. EVIDENCE: At the time of the inspection a number of residents were on holiday with staff in the Lake District. Activities are arranged for residents although there were occasions described by staff where these had to be cancelled due to lack of staff. Two activities worker posts are vacant at present. Both of these posts have been advertised. Some staff said that they feel that the range of activities available is restricted due to staffing problems. Examples were also given of when activities have been arranged then people do not wish to join in. One resident does voluntary work. A weekly activity plan was displayed in the office. Residents are encouraged to socialise with their own friends and family and may have weekend breaks at home. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 10 Menus were available and appear to offer an appealing diet to the residents in the home, who contribute to meal planning. The kitchen and food preparation areas have been refurbished since the last inspection. The contents of the fridge were examined and found to have opened items correctly labelled. All record sheets completed in dining areas relating to food temperatures must be dated. A 4- week menu cycle is in operation including healthy options. From discussions with staff it appears that the support workers do most of the cooking and shopping for food. It was noted that food temperatures have not always been recorded. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 11 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 standard(s) 19, and 20. Service users physical and emotional health needs are met, and there are satisfactory medication administration procedures in the home. EVIDENCE: Care plans examined show that the physical and emotional needs of residents are met. Some staff members expressed a concern that the continued heavy reliance on bank / agency staff may have a detrimental affect on the mental health of some residents. Residents present during the inspection were complimentary about staff and felt that they are well cared for. Some did comment that they were concerned about the fact that some staff have left the home. A requirement set at the last inspection that nutritional assessments must be in place for all residents has not been met. It was explained that this is due to difficulty locating a suitable body mass index to use with the assessment tool. Accident records were examined. All accidents and incidents are recorded appropriately. All residents are currently self caring and receive support as required. Medication administration procedures are satisfactory in the home. There were no unexplained gaps in records. It was noted that there is no counter upon 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 12 which to dispense medication. Medicines are dispensed from cupboards, which also house hoovers and other items. It is recommended that medication is stored and dispensed in a more suitable environment, although it is acknowledged that it may be difficult to find extra space. RMN’s receive regular refresher training and do “medicines for care homes” training. Some residents are being encouraged to self administer medication and will be provided with lockable storage for their medicines. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 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 standard(s) 22. service users feel their views are listened to and acted upon. EVIDENCE: A satisfactory complaints procedure is available. There have been no complaints since the last inspection. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 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 standard(s) 24 and 30. Service users live in a homely comfortable and safe environment. The home is clean and hygienic. EVIDENCE: The three premises were inspected and found to be nicely decorated and homely. The bedrooms of some residents were seen and found to be personalised and comfortable. There are some areas where wallpaper is peeling off the walls in corridors. One bedroom was found not to have hot running water. It is also recommended that residents in overlooked rooms be offered net curtains. Some lounge, corridor and a bedroom carpet are marked and must be cleaned or replaced. There are also some chairs with marked arms, which must be cleaned or replaced. An unstable white trolley in the bathroom should be replaced for something more secure and sturdy. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 15 Some new showers have been provided which provide easy walk in access. Cleaning in the home is carried out by support workers with some support from residents. Support workers follow rehabilitation plans to encourage independence. Laundry is also done predominantly by support workers. Support workers demonstrate a good understanding of COSHH regulations and cleaning chemicals are stored safely. They also demonstrate a good understanding of good hygiene and infection control. Detailed cleaning schedules and rotas ensure that the houses remain very clean and tidy. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 35. service users are not fully supported by an effective staff team. Service user nedds are met by appropriately trained staff. EVIDENCE: During the inspection qualified staff and support workers expressed serious concerns about the ongoing heavy reliance on agency staff. There are 5 vacant support worker posts (50 ) and these are filled on a weekly basis by agency staff. The home uses the same agency staff for continuity of care but despite this, morale appeared very low in the home on the day of the inspection. From discussions with staff, it appeared that low pay is a contributing factor to poor retention and recruitment of staff. A meeting was held with the manager and service manager of the home due to concerns regarding the impact this situation may be having on residents. They reported that a substantial pay rise has been agreed for support staff, which they will receive within the next two months. The manager also confirmed that morale is low at times but not all of the time. They also feel that despite the activities worker vacancies, social needs are being met. This will be monitored closely. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 17 Training records were not fully inspected during this inspection. The home is staffed by qualified nurses, (RMN’s), who feel they receive adequate training to enable them to do their jobs. There is a sleep in support worker and an RMN awake each night. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42. service users are confident their views underpin all self monitoring, review and development in the home. The health, safety and welfare of service users are promoted and protected. EVIDENCE: The manager of the home was not present on the day of the inspection. It was therefore not possible to assess some of the standards. Residents spoken to feel that in the main, their views are important to the process of monitoring in the home. Meeting minutes confirm that their views are sought. No formal service user surveys were observed during the inspection. It was noted that the office was a little disorganised on the day of the inspection, and it was reported that there had been a bit of a reorganisation, leaving things in a bit of a disarray. As RMN’s act as assistant home manager 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 19 in the absence of the manager, they must be able to easily locate information. It is recommended that the filing system in the office is reorganised to allow this to happen with an index system in place. The safety procedures in the home were examined and found to be generally good. A tour of the premises found that the homes are mainly safe. Random water temperature checks found the water satisfactory. Electrical items are PAT tested. Some emergency pull cords were found to be tied up and must reach skirting board level. Some concerns were expressed by staff regarding their personal security at night. Staff must go between bungalows and feel vulnerable. Although some steps have been taken with the provision of personal alarms, it was reported that staff still consider this a risk. Accident records were examined and found to be satisfactory. Weekly health and safety checks are carried out. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x 2 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 x x x x 2 Standard No 31 32 33 34 35 36 Score x x 2 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 115/117/119 Windsor Drive Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 2 x B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 21 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. 2. Standard YA19 YA42 Regulation 14.1(a) 13 (4) (a) Requirement Timescale for action 28/12/05. 3. 4. YA5 YA24 6 (a) 23 (2) (d) All residents in the home must have a Nutritional assessment completed. OUTSTANDING All pull cords must reach skirting Immediate board level. Food temperatures must be recorded. Statement of purpose and 28/12/05 service user guide must be updated. 28/12/05 Marked chairs must be replaced. Marked carpets must be cleaned or replaced. Damaged wallpaper must be replaced. The white bathroom trolley must be replaced. Hot water must be available in service user bedroom washbasin. Nets should be offered to service users with overlooked rooms. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 22 115/117/119 Windsor Drive 1. 2. 3. 4. YA20 YA39 YA42 YA33 Review medication dispensing and storage arrangements. Reorganise office space with index system for files. Security arrangements for staff at night are reviewed. Some work is done relating to team building and raising morale in the home. 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI 115/117/119 Windsor Drive B53-B03 S364 Windsor Drive V231571 280905 Stage4.doc Version 1.30 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!