CARE HOME ADULTS 18-65
Windsor House 8 Windsor Close Stevenage Hertfordshire SG2 8UD Lead Inspector
Louise Bushell Unannounced 5 May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Windsor House Address 8 Windsor Close Stevenage Hertfordshire SG 8UD 01438 813915 01438 813915 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Psycare Hostels Russell Fletcher Care Home 3 Category(ies) of MD MD Mental Disorder - 3 registration, with number of places Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 10.03.05 Brief Description of the Service: 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 House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first inspection of the year, taking place late morning to late afternoon. This was an extremely positive inspection, reflecting the positive comments made by both service users and staff at the home. Time was spent with the manager of the home discussing processes, policies and procedures including recruitment and care plans. The majority of time was spent with the service users engaging in activities that were available and talking with them seeking their views. Ten service users views were sought individually or as past of a group. What the service does well:
This was a positive inspection in terms of the needs of the service user being met, with many ongoing improvements being made to the environment. The home has clear policies and procedures that are well organised, maintained and accessible to all. The atmosphere throughout the inspection was calm and friendly, promoting a good relationship between staff and service users. Staff spoken with during the inspection were complimentary of the management style within the home. The ethos of working openly, honestly and with a transparent approach appears to be effective. The home has a stable staff team to promote continuity for the service users. The home is currently adapting and implementing a new care planning system. The care plan is clearly a working document, which is being regularly reviewed. Once complete, the care plans in place are good working examples of meeting individual and changing needs. All service users are supported within the Care Programme Approach framework and frequent reviews occur to ensure changing needs are continuously assessed and reviewed. The home has a sound system for the provision of training and many training courses are currently available and are being attended by the staff team. All staff members have clear defined roles and responsibilities ensuring that the home functions smoothly. Service users expressed that they were happy with the systems and the management and staff within the home. One service user stated that, “ although I know they are staff, they are also my friends and I can tell them anything that is worrying me, I am always listened too.” Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 6 Following a discussion with a service user that has recently moved into the home it is clear that the home has a comprehensive referrals process including trial visits to the home. The service user was able to describe the process fully and felt that at all stages he was informed and aware of the information. What has improved since the last inspection? What they could do better:
The home is currently completing new care plans. There is a need for these to be completed so ongoing reviewing and monitoring of changing needs can occur. Any limitations within the home must be fully documented on each service users care plan. All service users who have the right to vote must be supported and empowered to do so as they wish. Risk assessments are present within the home, however a number are still required to be completed to ensure that all aspects of safety have been covered for the protection of the staff and the service users. Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, 5 Prospective service users individual aspirations and needs are assessed and reviewed, enabling the service users and the home to continuously review the individuals care package provided. Information provided to the service users about the home and its terms is suitable to meet their needs and therefore enables the service users to make an informed choice about where to live. EVIDENCE: A comprehensive Statement of Purpose is held within the home and all current and prospective service users are provided with a copy. The Statement contains information for the service user to make an informed choice about where to live. The content is suitable to meet individual needs. Full assessments of each service users needs and aspiration are made before the service user moves into the home. The assessments carried out within the home are continuously occurring supporting and monitoring individual progress and needs identified. Qualified and competent people complete the assessments. The home also receives and seeks external specialist support to meet the individual service users needs. Whole life and CPA reviews occur within the home to support the service users in achieving and reviewing individual needs, goals and aspirations. Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 10 The admissions procedure to the home includes trial visits for the service users to make an informed choice about where to live. A contract is then drawn between the home and the service user. The contract includes the terms and conditions within the home and the rights of the service user. Following a discussion with a service user that has recently moved into the home it is clear that the home has a comprehensive referrals process including trial visits to the home. The service user was able to describe the process fully and felt that at all stages he was informed and aware of the information. The service user confirmed that they had signed a contract and this was held on their file. Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 10 Individual needs and choices within the home are being promoted to encourage and empower service user self-determination, participation and consultation EVIDENCE: 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 home is currently adapting and implementing a new care planning system. The care plan is clearly a working document, which is being regularly reviewed. Once complete, the care plans in place are a good working example of meeting individual and changing needs. All service users are supported within the Care Programme Approach framework and frequent reviews occur to ensure changing needs are continuously assessed and reviewed. Staff support all service users to take reasonable risks as part of independent living lifestyles. Those observed covered areas of risk such as deterioration of mental health state, violence to self and others, sleep disturbances, inappropriate sexual behaviour, selfWindsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 12 neglect and physical health and absconding. Risk assessment completion within the home is ongoing Service users confirmed that they are enabled and supported in making choices within their lives and were aware of their individual care plans. One service user discussed the involvement that he had had in the formulation of the plan. All care plans are signed. The home is still working towards the implementation of plans regarding limitations and restrictions within the home. All information within the home is handled in accordance to the Data Protection Act 1998. All records are held securely. Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 16 Personal development opportunities are encouraged for all service users ensuring interactions within the local community and that individual rights and responsibilities are recognised and supported. EVIDENCE: Service users have the opportunity for personal development within the home. Service users were discussing that many options are available to them within the home. Examples were given including development of independent living skills, socialising, working, voluntary placements, college and further education and training. All service users within the home access services within the community and were able to confirm that they were received effectively and through professional channels. The home is currently offering a number of service users the opportunity to receive paid employment through the completion of tasks such as gardening, cleaning and painting and decorating. Service users are encouraged to become part of the local community and many access the local community independently on a regular basis. All service users are supported in gathering relevant information regarding employment, further education, employment skills and benefit advice if required. Some
Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 14 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. A number of service users expressed that they were not able to participate in political voting this year. Some service users did express that they would have voted if on the electoral role. 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. Meals within the home are offered on a flexible basis and all service users are encouraged to participate in the cooking with appropriate support as required. The service users determine the menu and choose a weekly menu specific to the meals that they are encouraged to cook on a rota basis. The home then orders the shopping into the home. Feedback from the service users determined that this system works extremely well and encourages a homely group environment. Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 All personal and health care support is well maintained within the home ensuring individual needs, choices and preferences are met at all times. The management of medication is effective within the home ensuring that service users are protected and supported in the process. EVIDENCE: All personal and health care support is well maintained within the home ensuring individual needs, choices and preferences are met at all times. All care provided is individual and tailored to each person, with service users needs, choices and preferences being promoted. Assessments and reviews are continuously completed, through the CPA process, ensuring that the approach adopted by the home is person centred and holistic to each service users needs. Service users needs are supported with all aspects of their physical and emotional health and receive adequate and appropriate input from specialists such as community nurses, consultants, GP, dentists, opticians and dieticians. Information and advice is provided to all services users regarding general health issues. The home has a robust policy and procedure in place to support the safe administration, storage and receipt of medicines. All staff receive training prior to being deemed competent to administer medication Training opportunities within the home surrounding medication administration are sound. The home has recently been able to access external training surrounding medications
Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 16 within the home. The training is distance learning and all staff will be able to access this. The training also provides a good practice managers pack. Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23 The complaints procedure within the home is sufficient and adequate in order for the service users to feel that their individual views are listened too. Robust policies, procedures and training are in place to ensure service users are protected and safe. EVIDENCE: The home has a comprehensive complaints procedure in place, which details that all complaints are responded to within 28 days. A record is maintained within the home of complaints made detailing actions and outcomes as necessary. All service users have been informed about the complaints procedure. This is also on display within the home. Robust procedures are in place to ensure that service users are protected from abuse and harm. Staff receive suitable and adequate Protection of Vulnerable Adults (POVA) training, which is currently occurring within the home. Staff employed within the home are all subject to enhanced Criminal Records Bureau (CRB). Feedback from service users determined that there complaints are listened to and appropriate actions are taken. Comments were received from the service users regarding the relationship they hold with the staff and how they feel listened to and supported within the home. Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None These standards were not inspected on this occasion, as access to the house was not gained. EVIDENCE: These standards were not inspected on this occasion, as access to the house was not gained Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 19 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36 The home is suitably staffed with well-trained individuals ensuring that at all times service users needs can be met. Robust recruitment practices occur within the home ensuring appropriate checks have occurred on all staff for the safety of the service users. EVIDENCE: Staff spoken with during the inspection appeared very clear of their individual roles and responsibilities. Staff were seen to support the main aims and values of the home. All staff have received a copy of the Genera Social Care Council Code of Conduct. The home has clearly defined job descriptions and person specifications in place. Recruitment practices within the home appear well structured. All policies and procedures relevant to the home must be on site at all times. Supervision and appraisal occurs within the home and staff felt that this was a valuable process. The home has an effective staff team in place in 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
Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 20 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 NVQ’s and following notification form the company, achievements of standard is anticipated by July 2005 for all staff. A supervision record chart has recently been implemented into the home following the last inspection. Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 21 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39 The management within the home is secure and effective ensuring that changing needs of service users are met and that the home is running meeting its aims and objectives. EVIDENCE: 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 and is currently completing the NVQ Level IV Registered Managers award. 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. The manager of the home was present throughout the inspection. The staff spoken to at the time of the inspection felt that the openness and the approach of the manager is effective and fair. The manager felt that his management
Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 22 style was inclusive and positive promoting a solid team approach. Feedback from service users regarding the staff and the management approach within the home was extremely positive. 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. 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. Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 2 x 2 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 3 3 2 x x 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Windsor House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x x x I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 6 Regulation 15 (2) (a) & (b) Requirement 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. Any imposed restrictions must be detailed within the service users individual plan. The registered manager must ensure that all service users have adequate risk assessments held within their individual files for anticipated areas of high risk. Dates of implementation and review must be held to ensure accurate reviewing occurs. Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service user’s individual Plan and of the home’s risk assessment and risk management strategies. (Previous reqyirement madetime scale of 20.04.05 not met). Timescale for action 30th July 2005 2. 3. 7 9 17 (1) (a) Schedule 3 (3) (q) 13 (4) (b) & (c) 30th June 2005 30th July 2005 Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 25 4. 13 16 (2) (m) 5. 39 24 Service users rights to vote must be upheld and methods implemented within the home to facilitate this request if applicable to the service user. 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. (Previous timescale set had not been missed by the provider following inspection this has been increased). 30th June 2005 30th July 2005 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 Good Practice Recommendations The admissions policy should be forwarded to the CSCI Windsor House I52 s62311 Windsor House v226036 050505 stage 4.doc Version 1.20 Page 26 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Herts AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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