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Inspection on 04/10/07 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 4th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 no outstanding requirements from the previous inspection report, but made 1 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

There are good policies and procedures in place to protect tenants, and staff are well trained to recognise safeguarding issues and react appropriately. The home is run in the best interests of tenants who are actively supported to make the most of opportunities available to them. Tenants and staff say they think the quality of care provided in the home is very good and is improving all the time. Staff receive regular training and supervision which ensures they are up to date with best practice and encouraged to develop their skills. Staff feel well supported to carry out their jobs.

What has improved since the last inspection?

A number of areas have been redecorated since the last inspection making the home more pleasant for tenants to live in. Some new furniture has also been provided. A new manager has been appointed which has improved the organisation in the home, which was without a permanent manager for a long period. The format of record keeping has been reorganised making care records easier to read and locate. There are regular one to one sessions with tenants to ensure they have very regular opportunities to express their views, concerns or aspirations. New equipment such as DVD and TV ordered in response to clients request.

CARE HOME ADULTS 18-65 Windsor Drive ( 115) (117) (119) Howdon Wallsend Tyne And Wear NE28 0NX Lead Inspector Aileen Beatty Unannounced Inspection 4 October 2007 09:30 th Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 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 Vacant 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.V346287.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2006 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. Fees are £761 per week. There are two continuing care beds. A service user guide and statement of purpose is available for people who want to know more about the home. Inspection reports are also easily accessible. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last visit on (date). • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on the 4th of October and completed on the 10th of October 2007. During the visit we: • • • • • • Talked with people who use the service, staff, and the manager. There were no visitors present during the inspection. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit People living in the home are referred to as tenants. This term is therefore used throughout the report. We told the manager what we found. The overall standard of care was found to be extremely good. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There are plans to further develop the one to one sessions with tenants. A review of training and development procedures is taking place to improve the standard of staff supervision and development further. Some areas of the home such as the exterior woodwork requires attention as it is unsightly and damaged in places. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 7 There are plans to improve contact with relatives and carers. The health promotion that is already taking place will be further developed to help tenants make healthy lifestyle choices and receive regular check ups. 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. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 8 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.V346287.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive assessments are carried out before and after admission to ensure that people’s needs can be planned and properly met. Detailed information is available to help people make choices about the service before moving in. Admissions are carefully planned to help people to settle into the home. EVIDENCE: The statement of purpose for the home has been updated and contains information about the services and facilities available. This enables prospective tenants to make decisions about whether the home is suitable to meet their needs. There are some plans to make information more user friendly but the booklets available contain all of the required information. A preadmission assessment is carried out before anyone moves into the home. This involves staff from the home, the prospective tenant, consultant psychiatrist and any family carer or representative. This is to help to decide whether the home is the best place to meet the needs of the service user and to plan the admission. People may have an introductory visit, building up to overnight stays. Staff report that residents (or tenants which is the term used in the home), settle quite quickly. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 10 The records of existing tenants show that they have had a pre admission assessment of their needs and have been given a Community Integrated Care agreement. After two weeks in the home, baseline assessment information about their needs is gathered, and then again after eight weeks. This shows that the home is gathering the required information to ensure that care plans can be written which will be up to date and relevant. The information shows that tenants have been included in this process. There were no new tenants available during the inspection, but a new admission is planned and the manager described the process. This includes a staged introduction to the home, and there are plans to introduce a new procedure. This will ensure that new tenants are met by a named member of staff who will then also greet them when they visit the home. They will be shown around the home and invited to stay for a meal and then trial visit. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There are good procedures in place to ensure that the tenants needs and wishes are continuously assessed. There are regular opportunities for tenants to be consulted on all aspects of life in the home. EVIDENCE: Individual care records are held for each tenant in the home. Three of these were read and contain all of the required information to enable staff to assist tenants in meeting their needs. Care plans contain information about all aspects of personal, health and social care and tenants sign their agreement to these plans. Any health issues in care plans have supplementary information available alongside the plan describing the condition. There is a summary of every care plan with reminders for staff about what to report and record. A new member of staff said that they are aware of what should be recorded in care records and said that they have full access to records to read but that they must not be taken out of the office. They Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 12 demonstrated a good understanding of confidentiality, which is covered during induction. Daily activity plans are displayed in the office and are available to all staff. These plans are not rigid, but provide some structure to prompt staff and tenants about the aims of the care plans. Windsor Drive is a rehabilitation unit so there is a mixture of rehabilitation and social activity on each plan. Tenants are involved in all aspects of planning their care and leisure time. There are regular tenants meetings and the minutes of these are available. In addition to seeking views in meetings and group setting, the manager has introduced a system of giving all tenants one to one time with a key worker on a regular basis and is working towards offering this daily. All one to one sessions are recorded, and it is a time in the day when tenants are given a one to one opportunity with their key worker to discuss anything they wish. These have proven very beneficial and staff ask tenants if they may record these discussions by explaining that what they have to say is very important, and should be written down. Tenants are happy about this and staff report that they have noticed that some very important issues are addressed this way. The manager has ordered and offered keys to the front door to all tenants. Some prefer not to have the keys but one tenant spoken to said that they were very pleased to have their own keys and happy generally with the way that the home is run. They said that they are able to make choices about all aspects of their daily lives. A student nurse and new member of staff on duty both confirmed that tenants have choices, for example, they sign their own agreements and likes and dislikes are recorded. General and specific risk assessments are in place. There is good evidence of risk assessments being used and tenants being supported to take acceptable risks to enable them to lead a fulfilling life. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Tenants are well supported to develop and engage in a good variety of leisure activities. Rights and choices are promoted and protected. EVIDENCE: Individual activity plans demonstrate that tenants have access to a good range of activities on a regular basis in addition to other activities organised by the home. On the second day of the inspection, it was world mental health day, and there was a buffet and a display of art work in the home. People are invited to events but they have a choice about whether they wish to attend. Staff reported some recent success with engaging more tenants who were previously reluctant to take part in some activities. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 14 The philosophy of the home is to support inclusion and this is done through the use of local services. There is good evidence of close links with community services including the emphasis on tenants going out to appointments, rather than services being brought into the home. There is a rehabilitation focus in the care provided, with some tenants actively maintaining a good degree of independence while remaining at Windsor Drive. Other tenants have progressed to independent living schemes, with two people having progressed and moved out of Windsor Drive in the last twelve months. There have been some very successful holidays planned with tenants, and weekly plans show a diverse range of activities being carried out. A number of tenants said that they would like a new car as the current one is not very comfortable and one person said that they did not feel safe in it. As previously mentioned, tenants have choices about all aspects of their life. The manager described the commitment to encourage “self determination” and use current legislation such as the mental capacity act to help them to achieve this. Each flat has a kitchen and staff cook meals with tenants. There is a choice of food, and tenants spoken to said that they are able to choose what they would like to eat and that there are always alternative choices. Special diets such as vegetarian are catered for. Healthy options are encouraged and the home has a commitment to health promotion and education while respecting individual choices. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Personal support is provided in a way that meets the needs and preferences of tenants and is agreed by them. Staff are proactive in supporting tenants to remain healthy. Procedures for the administration of medicines are good and ensure that tenants remain safe while being as independent as possible. EVIDENCE: Care records show that tenants have access to their own GP, and any health checks are carried out off the premises. Tenants may have an annual or monthly health check, and are encouraged to maintain a healthy lifestyle. For example, there are healthy options included in menu planning, and the manager said that they are keen to further develop health promotion in the home. Activity plans and care records detail the level of support required by tenants with personal care. In most cases this may be a prompt, and all activity plans have been agreed by tenants indicating they are happy with the level of support offered to them. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 16 There are plans to encourage all tenants to see dentists and optician on a regular basis as part of the homes ongoing commitment to ensuring health needs pf tenants are fully met. New non smoking legislation has been introduced and there are designated smoking areas. A student nurse and new member of staff in the home were interviewed as part of the inspection process. One staff member said that there is a nice balance in the home between supporting people and allowing space and privacy. “ Tenants are encouraged to do things for themselves but are not badgered, people have their own space and privacy. This unit is what every mental health unit should be like, it is very homely”. There are plans to introduce a weekly well persons clinic to offer a forum for health checks and discussion of health issues, including personal issues relating to sexual, physical, mental or spiritual health. There are already regular health checks offered. Medication procedures in the home are good which means that medicines are stored and administered safely. Qualified nurses administer medicines and three tenants are responsible for their own. Regular medication competency checks are carried out but the manager plans to use a new format to assess the competence of nurses, which is more in depth. This will include nurses being able to describe the therapeutic use of each drug and the normal dose and any common side effects. A nurse currently visits the home to monitor the level of medicine in blood samples as part of the safe use of the medicine Clozapine. This service will be carried out at the GP practice in future. Medicines are stored safely and there are satisfactory procedures in place for the ordering receipt and disposal of medicines. It was noted throughout the inspection that the manager was very aware of issues concerning the health and well being of tenants in all three bungalows. On one occasion, he asked to interrupt the discussion with the inspector to check on a tenant who had been distressed earlier. On another occasion, a tenant came into the office and said something which indicated that they were upset. Again, the manager immediately picked up on this and went to investigate what the matter was. Tenants spoken to say that they feel well cared for. One said that staff are “canny” and “if you are quiet staff ask what’s up? They listen to you”. This was clearly evident during the inspection. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints procedure is in place and clearly displayed to ensure that that complaints are dealt with effectively and to the satisfaction of the complainant. Clear protection procedures are in place to protect service users from risk of harm. Formal training provided to all staff at the home which means that they recognise when to raise an alert. EVIDENCE: There has been one complaint since the last inspection. It was an internal one by a resident and it has been satisfactorily resolved. Complaints are recorded and acted upon. Safeguarding adults training is carried out to ensure staff know how to respond to adult protection issues. One member of staff spoken to demonstrated an awareness of the procedures to follow including the home’s whistle blowing policy. The home recognises that there are times when tenants may be at risk of causing harm or distress to one another, and where there has been potential for this to happen, it has been dealt with sensitively and professionally. The culture in the home recognises the need to protect the privacy and dignity of Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 18 all tenants in such circumstances. This was evident in discussions with the staff and manager. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The building is generally suitably homely, comfortable and safe. EVIDENCE: There are three bungalows at Windsor Drive. All have domestic proportions, which make the premises homely and comfortable. A number of areas have been redecorated since the last inspection. Two tenants showed the inspector their bedrooms which they both said they were very happy with. They were nicely personalised and homely. The home is generally well maintained but there are some areas that require redecoration and repair. The exterior of the bungalows has wooden fascias that are stained with a dark coloured stain. There are some areas where this is in need of re treating and in some instances replaced as it has become shabby, giving a poor first impression. The roofs on the conservatory areas are also in need of attention. Some of the woodwork is in a poor condition and some Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 20 glazing is damaged allowing condensation between the panes, which is unsightly and looks as though it is permanently raining. Some bathroom areas are clinical and bare in appearance. The manager is aware of this and has plans to redecorate these areas and also remove the bath hoist which is not required and is not in keeping with the domestic surroundings. The bungalows are clean and tidy. The manager is keen to encourage all staff to take care to pay attention to detail in the environment and keep the home looking nice. Staff meetings have been used to reinforce this. Tenants are responsible for cleaning their own rooms, with varying degrees of assistance. Checklists are in place to help staff to ensure the home is given a thorough clean on a regular basis. There are no domestic staff at present but there are plans to appoint a part time housekeeper to help with deep cleaning. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Tenants are well supported by competent well trained staff. Recruitment procedures are strictly adhered to, to ensure tenants remain safe. EVIDENCE: There are sufficient staff on duty in the home at all times, who are appropriately trained and competent. The home is staffed by qualified nurses (Registered mental Nurses) and support workers. There has been an improvement in the number of permanent staff employed in the home, with less reliance on agency or bank staff. A student nurse a new support worker were interviewed as part of the inspection process. The support worker is currently going through the company induction programme, which consists of computer based e learning modules. The manager is also working through the modules so that he is aware of the contents and can support staff effectively. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 22 Two staff files were read and contained all of the required information. Criminal records checks and two references for each candidate are available. The identity of each applicant is also confirmed with copies of passports, birth and marriage certificates. Tenants are involved in the recruitment process and spend time with candidates so that they are able to provide feedback to staff responsible for making the appointment. Tenants spoken to were complimentary about the staff in the home, and are happy with the appointment of the new manager. They also said “ I feel well looked after. I just tell people where I am going and if I don’t like something like lunch, I can just choose anything else and they will go and get it for me”. Staff said that they feel well supported in the home. When asked about a serious incident involving a tenant, both said that they were very well supported and in such circumstances there is always a debrief. This is an opportunity to talk through what has happened and other tenants are also included. There is a programme of training and development in place and staff are supervised on a regular basis. In addition to statutory training the manager is keen to get nurse involved in passing on their skills and experience to other staff. Staff have the opportunity receive NVQ training. The manager plans to further develop training plans over the next twelve months, including introducing systems of internal audit to ensure training and development procedures are followed. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run by a competent manager in the best interests of tenants. There are good procedures in place to protect the health and safety of staff and tenants. EVIDENCE: A new manager, Gary Sober has been appointed since the last inspection. He is an experienced mental health nurse and has applied to go through CSCI fit person process. There was evidence of excellent managerial practice but this needs to be backed up by the CSCI fit person interview and a period of sustained practice. This will be more easily reflected in scoring outcomes at the next inspection but it is important to note the progress made to date. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 24 During the inspection, there were a number of spontaneous references from staff and tenants about Gary’s management style. These included, “It is more organised and staff are happier and more motivated. There are more activities available to residents” “I am impressed with the small things, there is information in each flat and so everyone knows what they are doing. We are also accountable for what we do” “ Gary is a good manager. He is good at organising and has good plans”. “ Like one of the family, a good manager”. On both days of the inspection, there was also evidence to confirm the comments that the home is well organised. Staff and residents have clear daily plans to help provide some structure to the day. There was evidence of tenants being encouraged to make choices throughout the inspection. For example, some tenants have decided to decorate the conservatory smoking areas, while another said during a one to one session that they would like to practice their writing. They have been supported to seek a pen pal in a safe way through the company newsletter. Staff and manager are using these sessions to help to make sure that the rights and best interests of tenants are actively promoted at all times. It appears that this technique is having some success, and is being further developed. There are regular safety checks carried out in the home. These include inspection of fire alarm systems and equipment and a recent visit from the fire officer is recorded. Water temperature checks are carried out and there are still some rooms which can become too hot and this is under investigation. Due to the potential for some taps to become hotter, there are hot water signs in place. Statutory health and safety training is carried out on a regular basis and some safety training is included in the computer based induction. The woodwork in the conservatory area looks quite damaged in places and could potentially deteriorate to a dangerous state. The manager has already noticed this and has already raised it in line with company policy. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 25 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 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 3 3 3 X X 3 X Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 26 NO 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 YA24 Regulation 24.2 Requirement Repair or replace woodwork on the exterior of the building and in conservatory areas. Timescale for action 10/02/08 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 YA8 Good Practice Recommendations It is recommended that residents meeting minutes contain a reference to who is responsible for taking an item forward, and progress feedback at the next meeting. Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Windsor Drive ( 115) (117) (119) DS0000000364.V346287.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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