Inspection on 14/12/05 for Windsor Lodge

This inspection was carried out on 14th December 2005.

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

The inspector 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 20/03/07

Windsor Lodge 10/12/04

Windsor Lodge 12/07/04

Windsor Lodge 08/12/03

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Windsor Lodge Windsor Road Gerrards Cross Bucks SL9 8SS Lead Inspector Mrs Rosemarie James Unannounced Inspection 14th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Windsor Lodge Address Windsor Road Gerrards Cross Bucks SL9 8SS Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01753 662342 Mr Thomas Glynn Mrs Margaret Glynn Mrs Deborah Dry Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (9) of places Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th June 2005 Brief Description of the Service: Windsor Lodge is a small residential home for eight elderly people but is registered to provide care for up to nine persons to accommodate a couple who may wish to share accommodation. The home is privately owned and managed. The home is the family home of the proprietors who live on the premises. It is a large dormer style bungalow set within large landscaped grounds. Accommodation for service users is on the ground floor while the proprietors have accommodation on the first floor. The home is sited in a semi rural area on the edge of Gerrards Cross. All bedrooms provide single room accommodation unless a couple choose to share the one double room. Two bedrooms are en suite and there are additional toilets and an assisted bathroom. Communal areas are light and comfortable. Planning application was made for a conservatory to add to the facilities for service users but, to date, this has been denied by South Bucks Council. The home is accessed by electronic gates that are activated through a CCTV intercommunication system. The drive takes the visitor through the landscaped garden to car parking areas adjacent to the home. Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 14th December 2005 commencing at 10.00am. The inspector was Mrs Rosemarie James. During the inspection the inspector met with the residents, observed staff as they went about their daily tasks, looked at a selection of records and had a brief tour around the home. The registered manager helped with the inspection process. At the time of the inspection there were 7 residents at home with one in hospital. Windsor Lodge is a lovely home providing high standards of care. The inspector was made to feel very welcome and would like to thank the residents and staff for the hospitality shown to her during the visit. This is the second of two statutory inspections to be carried out in 2005. At the first inspection all the core standards were assessed and met. For a more complete picture of this homes performance it is recommended that this report is read in conjunction with the report following the inspection carried out on the 20th June 05. What the service does well: Windsor Lodge is a friendly family like home where the residents receive high standards of care. The staff offers a good service to older persons who need help with the activities of daily living. The residents and their families have a say in how the home operates. The manager describes her staff team as fantastic helping to create the positive environment evident to anyone who enters or visits the home. The staff work hard and this is recognised and appreciated by the proprietors and manager. A Christmas meal and earlier in the year, a spar day was paid for by the proprietors in appreciation of their staff. The records seen were of a good standard and stored appropriately. The environment is a real home from home and is well maintained. The grounds are simply breathtaking and attract an abundance of wildlife. Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this visit. The inspector can confirm that the core standards as detailed above were assessed at the last inspection and considered met. EVIDENCE: Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 &10 All the residents have a detailed care plan providing the staff with clear guidelines in how an individual is to be cared for. Good record keeping and effective relationships with a variety of healthcare professionals ensure the healthcare needs of the residents are well met. The ethos of this home and observed staff / resident interaction demonstrate that residents are treated with respect and that their right to privacy is observed. EVIDENCE: Since the last inspection in June of 05 the home have only had one vacancy and the care records of the resident admitted to this vacancy were amongst the records looked at. An admission sheet had been completed and it is pleasing to note that a key worker is identified at this point enabling them to be fully involved in the residents care right from the outset. There was a very detailed care plan in place that provided staff with step-by-step guidelines on how all the identified needs should be met. Risk assessments were in place including the written consent of relatives for the use of bed rails. The home is Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 10 commended for its good practice in including this resident in the falls protection management programme. A nutritional assessment had been carried out. There was evidence that the care plans are reviewed regularly and there was a letter on file from the residents’ key worker inviting the residents’ family to be involved in the review. At the time of the inspection the most up to date care plan had been sent to the family for them to comment on and make any additions / changes they felt necessary. A movement and handling risk assessment was also in place and again there was evidence of this being reviewed. Advocacy information was on file. Daily entries of a residents’ wellbeing are maintained. Good standards of recording were evident in particular following up on healthcare concerns. An example of the detail contained in the care plans is evidenced from one drawn up to deal with an incident of MRSA. The family had been informed, staff reminded of good hygiene practices, information leaflets given to the resident, protective clothing provided for the staff, visitors to the home were notified and there was district nurse involvement. The infection had quickly cleared. The inspector is confident that the steps the home put in place to deal with this situation played a large part in resolving the issue and bringing the resident back to good health. The records seen showed involvement with a variety of healthcare professionals and, as stated earlier, staffs recording of healthcare issues including follow-ups was particularly good. During the inspection it was observed that the staff had an excellent rapport with the residents and at all times treated them with dignity and respect, there was a lot of humour evident. All those residents that the inspector met with complimented the home and its staff, not one concern was raised. All the residents looked extremely well cared for. It was a recommendation of the last report that the home carries out a medication audit. This has been done. As a result a decision has been made to transfer the homes administration of medication over to a monitored dosage system although a final decision as to whom the pharmacy supplier will be is yet to be made. Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 13 The way the home operates and the range of social events on offer ensures the lifestyle, hobbies and interests of the residents meets their expectations. Visitors to the home are encouraged and contact with the community facilitated to ensure residents maintain contact with individuals outside of their living environment. EVIDENCE: On the day of the inspection residents in the lounge area were enjoying reading, watching TV (age appropriate), knitting and playing a game of patience. The majority of residents in this home are in there 90’s but extreme age does not prevent them from enjoying active social lives. Tuesday is craft day and recent activities include making mobiles and Christmas cards. Flower arranging comes courtesy of a volunteer from the Methodist Church and Friday’s are news days where the news of the previous week is discussed. Residents meetings are held every three months. Community contact comes via the Holy Cross School and St Joseph’s church that are both to visit the home to sing carols. Contact with St Joseph’s church is particularly close. During the summer months a fete was held in the grounds of the home to which family, friends and the local community were invited. In excess of £700 was raised for a local hospice. Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 12 Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this visit. The inspector can confirm that the core standards as detailed above were assessed at the last inspection and considered met. EVIDENCE: Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20,22 & 25 The communal areas both inside and outside of the home are very well maintained ensuring the residents live in safe and comfortable surroundings. Specialist equipment is provided for those residents who are less physically able thus ensuring they have as much independence as possible. EVIDENCE: As you drive up to the property you pass through simply breathtaking grounds that the residents have full access to and can enjoy throughout the year. The garden attracts an abundance of wildlife and bird feeders have been positioned so that residents can enjoy the antics of the birds that visit (including kingfishers and woodpeckers). The home itself is very domestic in style and character and provides the residents with a real home from home environment. All the bedrooms are single and were warm and welcoming on what was a cold winters day. The residents are encouraged to bring in their own possessions including items of furniture to help them feel at home. There was considerable evidence of this in all bedrooms with the rooms reflecting the characters and interests of their occupants. The property is well maintained Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 15 with the exception of one bedroom, which was in need of decoration. It has been agreed that this work will be undertaken within the next 6 months. Appropriate aids and adaptations have been made or are available for those residents less physically able. Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 & 30 Recruitment practices at this home ensure persons suitable to do so care for the residents. The home has a positive attitude to training helping to ensure that staff are competent to do their work. EVIDENCE: Since the last inspection there has only been the need to appoint one new member of staff. The recruitment records for this person were looked at. The records on file included: a completed application form, photo, completed induction checklist, a copy of the job description, two satisfactory references including one from the most recent employer, CRB and POVA clearances and copies of training certificates. There was evidence of regular supervision and annual appraisals are carried out. Although the staff rotas were not looked at during this inspection, staffing levels were appropriate on the morning of the inspection with input from both proprietors (this is normal practice). It was made a recommendation in the last report that challenging behaviour training was updated and that a training matrix for the home be developed. It is pleasing to be able to report that an update in challenging behaviour has taken place and that plans for training are recorded in the homes diary. At the time of this visit five staff have NVQ Level 2. Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed at this visit. The inspector can confirm that the core standards as detailed above were assessed at the last inspection and considered met. EVIDENCE: Although none of the above standards were assessed during this inspection, the inspector did look at accident reports and the fire logbook. There had only been one fall in the period between inspections and this was well documented. The fire logbook showed that fire alarm call points and emergency lighting tests were being carried out at the appropriate intervals. Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 x X 3 X 3 X X 3 x STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X x Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP19 Good Practice Recommendations It is recommended that within the next 6 months bedroom number 8 is redecorated. Windsor Lodge DS0000023033.V273148.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Aylesbury Area Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury HP19 8JR 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 DS0000023033.V273148.R01.S.doc Version 5.0 Page 21 - 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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