Inspection on 10/03/05 for Windsor House

Care Homes For Adults (18 ­ 65)Windsor House8 Windsor Close Stevenage Herts SG2 8UDAnnounced Inspection10th March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Windsor House Address 8 Windsor Close, Stevenage, Herts, SG2 8UD Email address Winnett@psycare.co.uk Name of registered provider(s)/company (if applicable) Psycare Hostels Name of registered manager (if applicable) Russell Fletcher Type of registration Care Home No. of places registered (if applicable) 3 Tel No: 01438 813915 Fax No: 01438 816713Category(ies) of registration, with (number of places) Mental disorder, excluding learning disability or dementia (3) Registration number I520002046 Date first registered 21st September 2004 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 21st September 2004 Yes NO 16.12.04 If Yes refer to Part CWindsor HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 310th March 2005 10:00 am Louise Bushell None None NoneID Code161584Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNone Mr R Fletcher ­ Registered Manager. Ms Anne Skinner. Mrs Kate Chalker-wye.Windsor HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers AgreementWindsor HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Windsor House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Windsor HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Psycare Hostels limited operates Windsor House. It is a Psychiatric Aftercare Hostel / Personal Care Home focusing on providing, psychological, emotional and practical support to 3 male persons with enduring mental health disorders. Windsor House (cluster home) is a three bed home situated within 100 metres from its sister home Winnett Cottage (core Home). The primary function of the cluster home is to compliment the rehabilitation programme commenced in the core home, providing a stepping stone into the community whilst working on the final stages of independent living. All service users living within Windsor House are able to access staff resources and support 24 hours a day. The home consists of three bedrooms and a communal bathroom on the 1st floor, a communal lounge and dinning room, kitchen, and down stairs toilet facilities on the ground floor. The home has a 24 hour pager system linked to the main core home. The home is situated down a lane with no through access to the public with ample parking facilities within a quite residential area.Windsor HousePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) In summary, this inspection was found to be positive. The inspector observed appropriate interactions between staff and service users of the core home. The inspector was able to meet one-service user residing in Windsor House. Access to the house occurred during this inspection and internal equipment and works were completed to a satisfactory standard with a homely, bright and clean feel throughout. Where information and details have remained the same following the last inspection this has been carried forward to this report. Choice of home (Standards 1 ­ 5). All standards were assessed and met. The home provides a structured assessment process for all service users within the home. The home has a detailed policy and procedure in place to support the service user and the staff through the process and the management of a new referral. The needs of the service user appear to be at the focus of the assessment process. The service users are offered a trial basis within the home and a contract detailing the terms and conditions is held on each clients file. The home continuously monitors and reviews the progress of the service users within the cluster home and if at any stage it is felt that further support is required the service user can utilise resources as support as determined by the individual need. Individual needs and choices (Standards 6 ­ 10). 5 standards were inspected, 2 were met and 3 partially met. All service users had care plans held on their individual files. All plans are service user focused and are aimed at increasing service user motivation and participation into community living. The Plan sets out how current and anticipated specialist requirements will be met, for example through positive planned interventions; rehabilitation and therapeutic programmes; structured environments; adaptations and equipment and one-to-one communication support. The home assigns a key worker to all service users. The home has a sound system in place to ensure that at all times the needs of the service user are met and the role of the key worker is maintained. The home must ensure that detailed care plans and risk assessments are completed, reviewed and implemented for all service users. Lifestyles (Standards 11 ­ 17). 7 standards were assessed, 5 were met and 2 partially met. Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. This was observed during the inspection in the manner and the approach of the staff to other service users within the core home. Service users have opportunities to learn and use practical life skills including user-led training. All Service users utilising Windsor House receive appropriate professionally validated interventions, Windsor House Page 6 counselling and therapy. Specialist interventions are available if required. Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Service users are encouraged and supported to pursue their own hobbies and interests. Any limitations and or restrictions must be documented within the service users plan. Personal health care and support (Standards 18 ­ 21). 3 standards were assessed and were met. The home has a comprehensive policy and procedure of the safe administration of medicines within the home. The home appears to operate a sound system of medication administration with only trained staff completing the task. All service users were self medicating and risk assessments had been completed. Concerns, Complaints and Protection (Standards 22 ­ 23). 2 standards were assessed and were met. The home holds a comprehensive and informative complaint procedure and policy. The home has recently reviewed the administrative management of complaints within the home and the new system appears to be well organised and easily accessible. Staff spoken to at the time of the inspection had a sound knowledge of the Whistle Blowing policy and the procedures to follow. The displayed clearly the guidance information leaflet and had a protocol manual. Environment (Standards 24 ­ 30). 6 standards were assessed, 3 were met and 3 were partially met. The home is in good decorative order throughout. It is bright, airy, comfortable and free from offensive odours. The home provides sufficient and suitable light, heating and ventilation. Furnishings, fittings, adaptations and equipment are good quality, unobtrusive and compatible with the needs of the service users. The home does not have a planned renewal and re-fabrication plan in place currently but is compiling a plan with records maintained. This to be forwarded to the Commission for Social Care Inspection. The home has still to obtain the electrical wiring certificate, Temperature check, water heating check for compliance with Legionella. Once complete this is to be forwarded to the Commission for Social Care Inspection. The home was clean and hygienic. All service users residing in the home support and complete the majority of the cleaning tasks. However, domestic support occurs once a month to focus on other areas. It is recommended that a cleaning rota and schedule be implemented to ensure a standard of cleanliness is maintained at all times, with specific tasks being rotated. Staffing (Standards 31 ­ 36) 3 standards were assessed, 2 were met and 1 was partially met. During the inspection it was observed that the staff spoken to support the main aims and values of the home, understand and implement the homes policies and procedures, and know how their work, and that of other staff (including key workers), promoted the main aims of the home. Staff have a clear understanding of their role within the home and were able to identify and demonstrate sound working practices within the homes ethos and good practices principles. Supervision of all staff must occur. There is a low use of agency staff within the home and staff take on over time as and when required to ensure consistency within the home. All staff received regular training. The company, Psycare Hostels, has a Senior Liaison Officer in post who coordinates all training and development for the staff. New development plans and performance appraisal files have been introduced for all the staff. Once fully functioning this system will be sound. Windsor House Page 7 Conduct and management of the home (Standards 37 ­ 43). 6 standards were assessed, 3 were met and 3 were partially met. The registered manager of the home is suitably qualified and competent to run the home. It appears that the management style within the home creates on open service user focused approach. The home is implementing a service user satisfaction questionnaire aimed at seeking the views of the service user. This will be distributed twice a year. The company is currently working on further developments to the quality assurance system in place with the aim of broadening its survey range to other professionals. The home must develop an annual development plan based on a systemic cycle of planning-action-review, reflecting aims and outcomes for the service users. All records required by regulation and inspected were available and up to date at the time of inspection with the exception of the water Legionella testing and the electrical wiring certificate.Windsor HousePage 8 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action None Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard None CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). NoneMET (YES/NO)Windsor HousePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 17 (1) (a) 1 YA15YA16 Schedule 3 YA7 (3) (q) 23 (2) (i) YA24YA41 YA42 2 13 (4) (c) Any record of any limitations agreed with the service user as to the service users freedom of choice, liberty of movement and power to make decisions must be documented on the individual service users plan. The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. All health and safety tests required by regulation must be completed. Effective quality assurance and quality monitoring systems, based on seeking the views of service users, must be in place to measure success in achieving the aims, objectives and statement of purpose of the home. Appropriate supervision must be in place within the home. By 15th May 2005By 15th May 2005By 31st May 2005 By 31st May 2005 By 31st May 2005324YA39418 (2)YA36515 (1) 15 (2) (b)YA6 YA7YA9All care plans and risk assessments are completed fully.Windsor HousePage 10 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * It is recommended that the home implements a detailed cleaning schedule to ensure a consistent hygienic level of cleanliness is maintained within the home. The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Where the provision of furniture is not evident within a service users room it is recommended that evidence of consent and agreement be documented. An annual renewal and redecoration plan should be developed.1YA302YA263YA24* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Windsor House YES YES YES YES YES NO YES NO YES NO YES YES YES YES NO NO NO YES NO YES Page 11 Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)1 X X NO YES YES YES 9 1 10/03/05 12:00 5The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Windsor HousePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 900.00 950.00 Range of fees charged From To £ £ (per week) YES Any charges for extras Toiletries and personal items and effects. If yes, please state what the extras are 3 Key findings/Evidence Standard met? Windsor House as the cluster home linked with Winnett Cottage has a detailed and comprehensive Statement of Purpose in place. The document is combined with the core home Winnett Cottage as they work simultaneously. The document contains all the information as per Regulation 4 and Schedule One of the Care Standards Act 2001. All service users are provided with these documents on admission and following review.Windsor HousePage 13 Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? The primary function of the cluster home is to compliment the rehabilitation programme commenced within the core home, by providing a further stepping stone into the community and advancing on independent living skills previously gained. The home provides on going reviewed assessments at each stage of the cycle to ensure appropriate levels of support are provided and tailored to individual levels. This is aided through the Care Programme Approach (CPA) assessment review involving a multi disciplinary approach to intervention with the service user. Psycare includes a consultant Psychiatrist, a consultant Nurse, Occupational Psychologist and the manager is a qualified Psychiatric and General Nurse. In addition to the team of staff the company employs a senior social worker and a senior occupational therapist that provides consultant sessions. Assessments are conducted and completed by these who are appropriately trained to do so. Evidence of ongoing assessments through CPA was viewed at the time of inspection. Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The management and the staff within the home are adequately trained and experienced to meet the need of the service users currently residing in Windsor House. The home is part of the core building situated on a different site. Persons are only placed within the cluster home following assessment in the core home. The cluster home provides a final stage for full integration into community living. Persons residing within the cluster home are able to access staffing resources and support 24 hours a day, however the staff are not based directly on site. The service users currently residing in Windsor House are also able to access facilities within Core home and will often partake in social activities with persons living within the core unit. The home continuously monitors and reviews the progress of the service users within the cluster home and if at any stage it is felt that further support is required the service user can utilise resources as support as determined by the individual need.Windsor HousePage 14 Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The home does not take emergency admissions, as it is a stepping-stone from the cluster home. There is a comprehensive Statement of Purpose and Service User Guide in place to provide all required and relevant information to any prospective service user. The home has a detailed referrals procedure in place that offers trail visits to the home, single over nights and a reviewing process for the service user and the home. All service users have an individual tenancy contract drawn up following a trial and review period. The service user is supported at all stages of the admission with continuous reviewing with the clinical team occurring, ensuring compatibility for the service user. This is through a multi disciplinary approach. Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? All service users have an individual tenancy contract drawn up following a trail and review period. The contract is held on their individual files and is signed by the manager and the service user. Where support is required to sign representation and the use of advocacy service can be utilised. The contract is in a format and language suitable to meet the needs of each service user.Windsor HousePage 15 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? The registered manager and staff team develops and agrees with each service user an individual plan, which includes treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. All plans are service user focused and are aimed at increasing service user motivation and participation into community living. The care plans and individual service users files are in the process of being updated. Many care plans were missing from individual files and or had not been completed. Some care plans had not been reviewed and were missing any implementation date and signature of the service user and or representative. A requirement has been made that all service user files and care plans are completed and audited as part of the supervision progress to ensure completion and sound monitoring of progress and works to be competed. Risk assessments were present in some of the files, however not in others even though a risk was present. A requirement has been made for all risk assessments to be completed as part of an effective risk management system. The Plan sets out how current and anticipated specialist requirements will be met, for example through positive planned interventions; rehabilitation and therapeutic programmes; structured environments; adaptations and equipment and one-to-one communication support. The plan is drawn up with the involvement of the service user together with family and or relevant agencies and specialists. Where a care plan and risk assessment has been completed they worked simultaneously with effective links to intervention required. The home assigns a key worker to all service users. The home has a sound system in place to ensure that at all times the needs of the service user are met and the role of the key worker is maintained. The role of the key worker is full understood by all service users within the home.Windsor HousePage 16 Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 2 Key findings/Evidence Standard met? Staff respect service users rights to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the Individual Service User Plan. Service users are encouraged and empowered to manage their own finances; where support is required it is offered and well documented for the reasons why. Currently all service users residing in Windsor House manage their own finances. The home has a visitors policy in place that places a restriction on visitors in certain areas, and at certain times within the home. This must be recorded in the individual services users plan. Service users are encouraged to participate in local independent advocacy groups / selfadvocacy groups and or to access further appropriate support if desired. Staff support all service users in the provision of information, guidance, assistance and communication support to empower them to make decisions about their own lives. The home is currently working with PohWer Advocacy Services. Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? The service users within the home are able to have access to all policies and procedures upon request. Service users participate in house meeting to discuss and concerns issues that they have regarding the running of the home. Minutes from these meetings are taken and a member of staff supports the process and acts as a link between the service users team and the staff team. Issues fed through to the management team are discussed and actions are taken as appropriate. The home operates an open door policy and any concerns felt can be discussed freely, openly but confidentially with all members of the team. Service users were able to confirm that they have received feedback about outcomes of their involvement and participation.Windsor HousePage 17 Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 2 Key findings/Evidence Standard met? Risk is assessed prior to admission according to health and social services protocols and in discussion with the service user and relevant specialists; and risk management strategies are agreed, recorded in the individual Plan and reviewed. Risk assessments are held and are specific to individual need. The home is currently reviewing its recording methods to ensure accurate and periodic reviewing of all are plans and risk assessments occur. Staff support all service users to take reasonable risks as part of independent living lifestyles. One service user was observed having adequate risk assessments in place. Those observed covered areas of risk such as deterioration of mental health state, violence to self and others, sleep disturbances, inappropriate sexual behaviour, self-neglect and physical health and absconding. The home has completed some generic risk assessments. The home is currently in the process of reorganising and updating all service user files and risk assessments. A requirement has been made that all care plans are completed for all service users and risk assessments are completed and held on individual files for all anticipated areas of risk, including service users smoking in their own bedrooms. The home must assess risk of new admissions according to health and social services protocols and in discussion with the service user and relevant specialists; this must then be agreed, signed and recorded in each individual plan and reviewed. Risk assessments must state an implementation date to ensure accurate reviewing of the document occurs. See Standard 6 for comments. Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? Staff respect information given by service users in confidence, and handle information about service users, in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. Service users and their families have access to the homes policy and procedures on confidentiality and on dealing with breaches of confidentiality, and staff explain and/or ensure service users understand the policy.Windsor HousePage 18 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. This was observed during the inspection in the manner and the approach of the staff to other service users within the core home. Service users have opportunities to learn and use practical life skills including user-led training. This is namely achieved through the identification and goals within their individual plans, which are inturn all individual and user focused. All Service users utilising Windsor House receive appropriate professionally validated interventions, counselling and therapy. Specialist interventions are available if required.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? Staff help service users to find and keep appropriate jobs, continue their education or training, and/or take part in valued and fulfilling activities. Service users can continue to take part in activities engaged in prior to entering the home, if they wish, or re-establish activities if they change localities. All service users are supported in gathering relevant information regarding employment, further education, employment skills and benefit advice if required. Some service users have an activities plan on their care plan which they have agreed and signed, this is aimed at promoting motivation and user participation and integration into community living.Windsor HousePage 19 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? See Standard 11 & 12. Staff enable service users integration into community life through: i. Knowledge about, and support for, service users to make use of services, facilities and activities in the local community (e.g. shops, library, cinema, pubs, leisure centres, places of worship, cultural centres); ii. Awareness or service users rights of access to public facilities under the Disability Discrimination Act 1995; iii. Maintaining a neighbourly relationship with the community; iv. Ensuring information and advice are available about local activities, support and resources offered by specialist organisations; and Ensuring access to transport ­ local public transport, accessible taxis, dial-a-ride, support to use it, to enable service users to pursue their chosen lifestyle and activities. A number of the service users residing at Windsor House are in current employment. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Service users are encouraged and supported to pursue their own hobbies and interests. See Standards 11, 12 & 13.Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 2 Key findings/Evidence Standard met? Staff support service users to maintain family links and friendships inside and outside the home. Family and friends are welcome within the home and involvement is encouraged however on agreement with the individual. All service users are able to choose whom they see and when: and can see visitors within their rooms and in private. Service users are able and empowered to meet people and maintain personal relationships with people of their choice, advice and specialist guidance is provided to support service users to make appropriate decisions. See Standard 16 & 7 with regards to restrictions on visitors.Windsor HousePage 20 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 2 Key findings/Evidence Standard met? The daily routines within the home promote independence for all service users, using a person centred approach at all times. Staff were observed to interact with all service users well and it was clear that mutual respect was held within the home for both staff and service users. Service users are able to receive visitors within the home; a visitors policy is in place. Following discussions with a member of the management team it was determined that there are restrictions for visitors and the service users with regards to private meetings within the home. A communal lounge and dinning room is available. The inspector was informed that visitors are unable to meet in the service users bedroom for prolonged periods of time. Any restrictions must be agreed and recorded within all service users care plan. A further requirement has been made that this be documented for all service users. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Service users are able to cook and provide their own meals. The core home completes a weekly shop with the service users decisions on the menu. All service users are able to decide on the finer details of the menu available and staff support to encourage them to choose a healthy option. The service users residing in the cluster home are provided with a weekly shopping budget and complete the weekly shopping on a rota basis. The core home receives meat and vegetables from a local supplier and this is distributed to the service users in the cluster home depending on personal preference and choices made. The service users purchase additional items independently as they desire. Meal times are flexible to meet individual need. Support is offered as required.Windsor HousePage 21 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Staff are able to provide a flexible and person focused approach to the care that is provided within the home. The service user and the staff within the home predetermine the provision of care. All aspects of support to be offered are well documented and clear guidelines are in place to support the service user and the staff team.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence Standard not assessed on this occasion. Standard met? XX 0Windsor HousePage 22 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. Consent is sought by the service user for the administration and retention of medication. Records are kept of all medications received into the home or disposed to ensure safe working practices. All staff that administer mediation receives detailed training prior to being deemed competent. Service users in the home are able to self medicate and the records reflected this. The home has a policy regarding self administration of medication. Risk assessments have been drawn up and are held on the medication file. It is recommended that these also be retained directly on all service user files for a consistent approach within the home. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? Staff and service users within the home are supported to discuss and deal with issues surrounding death, dying and bereavement. All service users have a funeral plan within their care pan and appropriate support has been provided for the drawing of these arrangements.Windsor HousePage 23 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? The home holds a comprehensive and informative complaint procedure and policy. The home has recently reviewed the administrative management of complaints within the home and the new system appears to be well organised and easily accessible.Windsor HousePage 24 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX3 Key findings/Evidence Standard met? Robust procedures for responding to suspicion or evidence of abuse or neglect (including whistle-blowing) ensure the safety and protection of service users, including passing on concerns to the Commission for Social Care Inspection in accordance with the Public Interest Disclosure Act 1998 and Department of Health (DH) guidance No Secrets. Staff spoken to at the time of the inspection had a sound knowledge of the Whistle Blowing policy and the procedures to follow. The displayed clearly the guidance information leaflet and had a protocol manual. Staff were able to discuss the procedure and displayed a clear understanding of this. Training is also being provided.Windsor HousePage 25 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? The home is in good decorative order throughout. It is bright, airy, comfortable and free from offensive odours. The home provides sufficient and suitable light, heating and ventilation. Furnishings, fittings, adaptations and equipment are good quality, unobtrusive and compatible with the needs of the service users. The home is carpeted throughout and is regularly cleaned due to heavy wear and tear. Bedrooms of service users are individualised and contain a lockable safe for personal and valuable items. The home is in keeping with the local community and has style and ambience that reflects the homes purpose. The home does not have a planned renewal and re-fabrication plan in place currently but is compiling a plan with records maintained. This should be forwarded to the Commission for Social Care Inspection. The home has still to obtain the electrical wiring certificate, Temperature check, water heating check for compliance with Legionella. Once complete this is to be forwarded to the Commission for Social Care Inspection.Windsor HousePage 26 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence Standard not fully assessed on this occasion. NO YES NO 3 X X X Standard met? 0 2 1X X X XWindsor HousePage 27 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 2 Key findings/Evidence Standard met? The inspector noted that home does not provide all of the furniture in the services bedrooms as stated within the standards. Due to the personal choices made by the service users all furniture is not provided. However, consent should be sought from the service user, friend, family or representative detailing the reasons for the non-provision of certain items of furniture within the service users room.Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The home currently has the use of two toilets, a bathroom and a shower room. All facilities are easily accessible to all service users.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The service users residing at Windsor House have the use of all shared space, this includes a garden area, kitchen, dinning room, lounge, bathroom and separate down stairs toilet. The home is proportionate to the needs to the service users.Windsor HousePage 28 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? The home has a sound system in place to ensure that satisfactory arrangements are made for the repair and maintenance of equipment in general or individual use to ensure its continued safety. The home has a call bell link and link telephone system to core home Winnett Cottage, this is to support the service users and for the event of emergencies.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 2 Key findings/Evidence Standard met? The home was clean and hygienic. All service users residing in the home support and complete the majority of the cleaning tasks. However, domestic support occurs once a month to focus on other areas. It is recommended that a cleaning rota and schedule be implemented to ensure a standard of cleanliness is maintained at all times, with specific task sbeing rotated. The laundry facilities are sited within the communal kitchen area. If support or advice is sought the service users have access to 24 hour support. Two of the service users residing in the home have completed the intermediate level Food Hygiene certificate. The home provides all relevant information and colour coded chopping boards to the service users to minimise risk of cross infection and contamination. Due to the nature of the home and the promoting of independence and integration into community life the presence of staff within the home is kept to a minimal except through individual service user plans where a need has been identified. The home has recently implemented health and safety testing within the home including fridge and freezer checks, hot water testing and core food probing. These are completed by the service users with support and verbal prompts from the staff. Staff will complete these vital safety checks in the absence of the service users.Windsor HousePage 29 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The home has an effective staff team in place with sufficient numbers with appropriate skills to meet and support the service users within the home. Records show that staff levels are of a satisfactory level and ratio to meet the service users needs. Regular staff meetings occur within the home and records were seen. There is a low use of agency staff within the home and staff take on over time as and when required to ensure consistency within the home. All staff received regular training. The company, Psycare Hostels, has a Senior Liaison Officer in post who co-ordinates all training and development for the staff. New development plans and performance appraisal files have been introduced for all the staff. Once fully functioning this system will be sound. The Registered Manager is currently completing his NVQ Registered Managers award and anticipated completion is July 2005. The remaining staff have all commenced their NVQs and following notification form the company, achievements of standard is anticipated by July 2005 for all staff.Windsor HousePage 30 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXXKey findings/Evidence Standard not fully assessed on this occasion.Standard met?0Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? Standard not assessed fully on this occasion.Windsor HousePage 31 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? The home has a training and development plan in place. There is an individual named person who is responsible for the training and development within the home. All staff have a structured induction programme which covers mandatory training ensuring that they are adequately trained and qualified to support the service users needs. Each individual staff member has a training and development assessment profile, which is linked to the annual appraisal and supervision system within the home. The implementation of this process is recent within the home so progress is yet to be evident, however it must be noted that the system appears to be very robust and comprehensive. The home is currently exploring options available to them surrounding POVA training. The training schedule is service user led and training to ensure the changing and developing needs of the service users is provided. The training is available through attendance at external course out side of the company, external course provided by the company and in house training by the training and development manager. The home also seeks further advice and internal training needs through local clinical specialists and services. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 2 Key findings/Evidence Standard met? Staffs supervision is currently not recorded and is informal. The home is working towards completing one to one formal clinical supervision. A requirement has been made the NMS state that this should occur at least 6 times a year. It is also recommended that the home implements a supervision recording sheet so the inspector is able to have visual clarification that supervisions are occurring.Windsor HousePage 32 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. YES3 Key findings/Evidence Standard met? The current registered manager of Windsor House has had over twenty years experience of working in the field of mental health care and is a qualified and registered mental health care nurse. He has been responsible for and has managed nursing aspects of several units in general and forensic Psychiatry settings with experience in both hospital and community based settings.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The manager of the home was present toward the end of the inspection. The staff spoken to at the time of the inspection felt that the openness and the approach of the manager was effective and fair. The manager felt that his management style was inclusive and positive, promoting a solid team approach.Windsor HousePage 33 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 2 Key findings/Evidence Standard met? The home is implementing a service user satisfaction questionnaire aimed at seeking the views of the service user. This will be distributed twice a year. The company is currently working on further developments to the quality assurance system in place with the aim of broadening its survey range to include other professionals. The home must develop an annual development plan based on a systemic cycle of planning-action-review, reflecting aims and outcomes for the service users. The home however does provide service user meetings where service users have the opportunity to discuss and raise any issues as they arise. The home also receives independent Regulation 26 visits in which development and actions are identified. Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? Policies and procedures observed throughout the inspection were seen to be comprehensive in detail and were accessible to all.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met ? All records required by regulation and inspected were available and up to date at the time of inspection with the exception of those highlighted within Standard 24.Windsor HousePage 34 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Please see Standard 24.Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met ? Standard not assessed on this occasion.Windsor HousePage 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorLouise BushellSignature Signature SignatureRegulation Manager Helen Pettengell DatePublic reports It should be noted that all CSCI inspection reports are public documents. Windsor House Page 36 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 10.03.05 and any factual inaccuracies: Please limit your comments to one side of A4 if possible We are working on the best way to include provider responses in the published report. In the mean time responses are available on request from the hertforshire are office.Action taken by the CSCI in response to provider comments: Windsor House Page 37 Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. ,You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Windsor HousePage 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Russell Fletcher Russell Fletcher Manager 25.04.05Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Windsor HousePage 39 Windsor House / 10th March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000062311.V209262.R01© This report may only be used in its entirety. 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