Inspection on 13/09/05 for Windsor Lodge

This inspection was carried out on 13th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Windsor Lodge 16/05/07

Windsor Lodge 13/07/06

Windsor Lodge 26/01/06

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Windsor Lodge 43 Cranford Avenue Exmouth Devon EX8 2QD Lead Inspector Belinda Heginworth Unannounced 13 September 2005 th 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 Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Windsor Lodge Address 43 Cranford Avenue, Exmouth, Devon, EX8 2QD 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) 01275 334150 Networking Care Partnerships (SW) Ltd., Suite 1, Westway Farm, Wick Road, Bishop Sutton, Bristol, BS 39 5XP Karen Farrelly Care Home 11 Category(ies) of LD - Learning Disability (11) registration, with number PD - Physical Disability (11) of places SI - Sensory Impairment (1) Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3rd February 2005 Brief Description of the Service: Windsor Lodge is a detached three storey building in a residential area of Exmouth. The home also has a one-bedroom annexe. The main house provides accommodation and personal care for up to 10 service users with a learning or physical disability over the age of 40. The annexe provides personal and supportive care for one resident. Although both the annexe and main house are registered as one home. They are run as two separate units. Networking Care Partnerships are the providers of the home. Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three hours. The manager was not present. Some residents living at the home have limited verbal communication skills and were therefore were unable to contribute fully to the inspection process. Time was spent talking with some residents and observations were made throughout the inspection. Two staff were consulted and their views on the home were discussed. The inspector looked round parts of the building and a number of records were inspected. The annexe was not inspected on this occasion. What the service does well: What has improved since the last inspection? Improvements have taken place around the home. Making it more homely. For example the toilets on the second level have been re-decorated and laundry room has been tiled making the surfaces washable. Window restrictors have been fitted to all windows and temperature control valves have been fitted to all radiators. This ensures that residents’ safety and welfare is protected. Residents have their own bank accounts where benefits are paid. Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3 & 5 Resident’s benefit from a good assessment process that ensures that the home is able to meet their needs. Some improvements are needed to the admission practice to ensure residents receive information about the terms of living there. EVIDENCE: Residents were unable to remember the assessment process prior to their admission to the home. A detailed assessment of need is completed to ensure the home is able to meet that person’s needs prior to admission. Residents are admitted to the home on a trial basis before making a decision to live there. Residents are given a contract on admission. The contract is completed by the funding authority and provides limited information. There was no evidence that residents had received a letter from the home saying it was able to meet their needs. There have been no new admissions since the new provider purchased the home but they are aware of this requirement. Not all of the residents have a statement of the terms and conditions of living in the home. This would provide additional information about what is included in the fees and what extra costs the resident might have to pay for. Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Residents’ privacy and dignity are met and promoted by the staff. Improvement is needed in the care planning process to ensure that staff are aware of residents’ needs and goals. Improvements are also needed areas of individual risk. EVIDENCE: Residents who were able said that staff consult them about all aspects of their lives. Staff were observed to be respectful and caring, and offering choices to residents. The manager is in the process of reviewing the care planning process and formats in the home. One file contained an extremely limited plan of care. In this particular case no risk assessments were completed. This means that staff are not provided with information to meet residents’ needs safely. Staff record daily events about each resident in one book. Some of this information is personal and should be recorded in individual records to ensure privacy and confidentiality. Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 & 15 Residents use the local and surrounding community for leisure pursuits. EVIDENCE: Residents talked about how much they enjoyed going out to the local shops, going for walks and using the pubs and cafes for drinks and meals out. The staff work hard to encourage and support residents in all types of activities. These include attending church services and activities arranged through clubs the residents attend. The manager also employs a drama therapist to come in once a week to carry out drama sessions in the home, which residents said they enjoyed. An art therapist used to be employed in the same way. Residents said they used to enjoy that but this was stopped when the new providers took over due to costs. Residents said they had good contact with family and friends and staff supported them in maintaining contact. Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 & 20 Residents’ health care needs are well met but some improvements are needed in the administration of medication and training for staff. EVIDENCE: Most residents were unable to discuss their health needs due to limited verbal communication skills. Some residents said they felt they were well taken care of. Staff demonstrated a good understanding of residents’ health care needs. Care plans provided further evidence that health care needs were assessed, monitored and met. On the whole medication records were good. However, some medication was past its shelf life and some eardrops did not have the date of opening. As most drops have a shelf life after opening it is important that staff are aware of when it is no longer safe to use. Some medication prescribed by the GP was handwritten in the administration sheets but it did not provide any instructions on how to give the medication and how much to give and what the medication was called. This is an unsafe practice. The entry was not signed. Most staff have received in-house training by a pharmacist on how to use the monitored dosage system. New staff have received training from the manager, who has also carried out an assessment to ensure they are competent. All staff should receive accredited training in the safe handling of medicines and the Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 12 manager should carry out regular assessments of competencies to ensure residents safety and welfare is well protected. Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 Residents are not fully protected from the potential of financial abuse. EVIDENCE: Residents have bank / building society accounts where some benefits are paid. Some of these accounts are operated by cash cards that only the staff are able to use. When money is taken out of these accounts the money is entered in a book, at the home, in the name of the resident. The money is kept in individual wallets in the home’s main safe. There are no signatures for each entry and no regular checking of the balance of monies held and there is no policy in place on the use of the cash cards. This system has the potential to be abused. It is unclear what the benefits are and confusion over how much is personal spending and how much is disability allowances. In one instance a resident was receiving less personal allowance per week than what the benefits agency wrote saying they were entitled to. In another safe, residents’ weekly spending money is kept. This money comes from the main balance of monies held in the main safe. The money is transferred to this system as and when needed. Two staff signatures and sometimes residents’ signatures are obtained for each transaction and receipts are kept. Two staff check these monies at each handover period. Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 Residents live in a homely and comfortable environment. Improvements are needed to some environmental risk assessments. EVIDENCE: The home is bright and cheerful with a warm homely atmosphere. The Annexe was not inspected on this occasion. Residents in the main house share a large lounge, dining room, kitchen and conservatory. Some residents showed the inspector their bedrooms. They were decorated and furnished to residents’ tastes and preferences. A laundry room is shared between the main house and the annexe. It has recently been tiled making all of the surfaces washable. Some toilets have recently been decorated and have new flooring. Window restrictors have been fitted to all windows to ensure the safety of residents. Temperature control valves have been installed to baths ensuring the risk of scalding is reduced. Radiators are thermostatically controlled which ensures they do not become too hot therefore protecting residents’ safety. The new providers agreed to fit radiator covers within twelve months of purchasing the home. However, until the radiator covers are fitted assessments of risk must Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 15 be completed. Currently risk assessments state that the radiators are thermostatically controlled. There is no mention of the fact they are uncovered and who might be at risk from that. There is no information on how any risks identified can be reduced until the covers are fitted. Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 Residents are not full protected by the home’s recruitment practices. EVIDENCE: Two new staff files were inspected. Only one reference could be found for each staff and police check certificates (CRBs) were not available for inspection. The manager said that the CRB had been obtained for one and the issue number was recorded. The manager said that the second staff had had a POVA first check completed. There was no recorded evidence of this. All other documentation necessary to protect residents was in place. To ensure residents’ welfare is fully protected staff must not be employed until written references are obtained before they start work in the home. CRB certificates must be available for inspection. Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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) 42 The health & safety of residents are protected. EVIDENCE: The manager completes a questionnaire prior to the inspection. This provides conformation that relevant and appropriate polices and procedures are in place and have been updated. This ensures that staff and residents’ welfare and safety are protected. The fire logbook was not inspected on this occasion. Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x 2 Standard No 22 23 ENVIRONMENT Score x 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x x 1 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Windsor Lodge Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 19 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard ya5 Regulation 5 (1) (b) Requirement The registered person shall produce a service users guide which shall include - b) the terms and conditions in respect of accomadation to be provided for service users, including as to the amount and method of payment of fees. Timescale for action 30/10/05 2. ya6 15 (1) (2) (a,b,c,d) (This refers to the fact that not all service users have terms and conditions and those who do are not up to date) Unless it is impracticable to carry 15/10/05 out such consultation, the registered person shall after consultation with the service user, or a representative of his, prepare a written plan as to how the service users needs in respect of his health and welfare are to be met. The registered person shall - a) make the service users plan available to the service user, b) keep the service users plan under review, c) where appropriate and, unless it is impracticable to carry out such consultation revise the service users plan and - d) notfiy the service user of any Version 1.40 Page 20 Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc such revision. (This refers to the lack of some care plans and the fact other care plans are not used by the staff) The registered person shall make arrangements, by training or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. (This refers to the lack of assessments of risks in some service users files) The registered person shall make arrangements for the recording, handling and safe keeping, safe administration and disposal of medicines received into the care home. (See narrative under section 18 - 21) The registered person shall make arrangements, by training or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. (See narrative under section 22 -23) The registered person shall make arrangements, by training or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. (This refers to the lack of assessments of risks in relation to the lack of radiator covers) The registered person shall not employ a person to work in the care home unless - the necessary documenation within this Regualtion have been obtained (This refers to not having 2 references in place before employment) Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 21 3. ya9 13 (6) 15/10/05 4. ya20 13 (2) 15/10/05 5. ya23 13 (6) 15/10/05 6. ya24 13 (6) 15/10/05 7. ya34 19 & 17 15/10/05 The registered person shall ensure that records refered to within Regulation 17 are at all times available for inspection in the care home by any person authorised by the Commission to enter and inspect the care home. (This refers to not all CRB certificates being available for inspection and no written evidence that a POVA first check had been completed) 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 ya20 Good Practice Recommendations The medication training for care staff responsible for the adminsitration of medicines in the care home, should be accredited and must include information set out in the National Minimum Standards for Adults (20.10). The manager should also complete regular assessments of staff compentencies in relation to medication. Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Exeter Office, Suites 1 & 7, Renslade House Bonhay Road Exeter, EX4 3AY Tel: 01392 474350 National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Windsor Lodge D54-D06 63309 Windsor Lodge 242932 130905 Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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