CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65
Windsor Lodge 43 Cranford Avenue Exmouth Devon EX8 2QD Lead Inspector
Belinda Heginworth Unannounced Inspection 16th May 2007 08:50 Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Windsor Lodge Address 43 Cranford Avenue Exmouth Devon EX8 2QD 01395 263211 01395 223154 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) Networking Care Partnerships (SW) Ltd Karen Farrelly Care Home 11 Category(ies) of Learning disability (11), Physical disability (11), registration, with number Sensory impairment (1) of places Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th July 2006 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 people with a learning or physical disability over the age of 40. The annexe provides personal and supportive care for one person. Although both the annexe and main house are registered as one home. They often run as two separate units. Southern Cross Health Care operates the home with a subsidiary company called Active Care who is in charge of general operations. The home’s current fees range from £343.73 to £2448 with extra costs for personal items such as hairdressing, toiletries and so on being charged individually. Inspection reports are displayed in the entrance hall of the home, making them available to visitors and the people living in the home who wish to read them. Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday over a period of about 6 hours, starting at 08.50am. The manager was present during the majority of the visit. Prior to the inspection the manager completed a questionnaire, which provides information about the people living at the home, staffing, fees and confirms that necessary policies and procedures are in place. This information helps the commission to prepare for the inspection, send out surveys to appropriate people and helps us form a judgement on how well the service is run. Surveys were sent to the ten people currently living at the home. Surveys were also sent to ten staff, four health care professionals, five care managers and ten relatives. Three responses were received from the people living in the home, three from health care professionals, three from relatives, two from care managers and one from staff working at the home. Their comments and views have been reflected throughout this report. Some of the people living in the home have limited verbal communication skills, time was spent making observations of how staff engaged with them, what activities they did and the general atmosphere of the home. Four people living in the home were spoken with individually, in private, where their views of their experiences of living in the home were discussed. Three staff were spoken with and time was spent with the manager. During the inspection we looked in depth at the files of three people living at the home. We also spoke, where possible, to those three people, made observations, spoke with staff and read records, starting from the admissions process through to the present. Medication practices were looked at and a tour of the home took place. We spent time in the annexe and inspected other records. These included, the fire safety information, menus, quality assurance records and recruitment files. What the service does well:
Staff work hard to ensure peoples’ needs are met. Most of the staff team have many years of experience of working in care and have received a good level of training. Some recently recruited staff are receiving a good level of induction training to help them to understand and meet people’s needs. During the inspection staff were observed being kind, caring and respectful. People who were able spoke with fondness of the staff and it was clear throughout the inspection that there were good relationships. A response from relative about the care said “I am really impressed with the skills and care we experience from the manager and her team”. A care manager in response to a
Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 6 survey said “the care service meets the needs of individuals it provides for, as best they can, considering staffing constraints. Staff have developed good working relationships with the service users who appear, on the whole, happy and settled”. Good information is provided in people’s records, which ensures staff have the knowledge to understand people’s needs and care for them safely. Some improvements in some of these records will ensure peoples’ wishes and goals are included. Health needs are monitored and well met with people attending health appointments. People are able to go out for social activities, these ranged from swimming, clubs, cafes, pubs, shopping, day centre, art and craft and walks. One person talked about going out shopping, helping doing work around the house and looking for work. During the inspection one person went out independently to go to Exeter using public transport. Some small improvements are needed when people are in the home during the day. (See “what they could do better”) The home works hard to support people in making decisions about their lives and giving them choices in what how they prefer to live. The manager carries out regular reviews of the service as a whole to ensure the home is being run in the best interests of the people living there; and the home is safe. They seek the views of many people, including relatives to ensure everyone is happy with the services they provide. What has improved since the last inspection? What they could do better:
Peoples’ records provide a lot of information but do not always include short or long term goals, and where they are included, staff do not always record whether the goals have been met. The home provides a range of activities out of the home and has an organised activity once a fortnight in the home. However, many people are left to their own devices when in the home. The interactions between staff and people are good but there was little individual time spent with people, for example, doing puzzles, chatting away from others, watching TV together and so on. Small amendments are needed to medication records to ensure practices are safe, for example ensuring there are two signatures for hand written entries on medication administration sheets. This will ensure that what is being written is
Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 7 checked for errors. In some cases when medication was not given or was refused, the appropriate administrative codes were not always being used. This means staff might be unaware of why the medication had not been given or taken. Although all staff who administer medicines have received training, the manager has not regularly assessed their competencies. This will ensure staff remain competent to give out medicines. Financial records are, on the whole, well kept. When “pocket money” is given to someone, only one staff signs to say it has been given. Because this money is given to a person to spend as they wish, therefore having no receipts, it would be a safer practices to ensure the giving of the money is witnessed by a second staff and both staff sign to confirm has been given. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 (Adults 18-65) and 3 (Older People) Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The admission process ensures people can make an informed choice of where they would like to live and be assured the home can meet their needs. The assessment process also provides staff with the information they require to ensure peoples’ needs can be met. EVIDENCE: The majority of people living in the home have done so for a number of years. Only one person has been admitted within the last year and a half. The assessment process prior to admission ensured the home could meet their needs. The person and their family were provided with enough information to make an informed choice of whether the home was suitable. Assessments had
Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 10 been completed for everyone living in the home. These help the staff produce a care plan and assess any risks. Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices
The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 (Adults 18-65) and 7, 14 & 33 (Older People) Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Staff are provided with information to help meet peoples’ needs and provide some choices over their lives, but their wishes and goals are not always planned or monitored. This means there is a risk of inconsistency in how care is delivered and no system to ensure the care is what the person needs or wants. EVIDENCE: The home has good information to inform staff of peoples’ needs and risks. Two people spoken with said they were involved in decisions about their lives
Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 12 and the information in their files. Relatives are invited to review meetings and care managers have recently carried out reviews on all of the people living at the home. In a response to a survey a care manager said they found the records were kept up to date and said the home was good at involving people in decision making processes. In response to surveys 3 people said they were always involved in decisions about their lives. Although staff have a good knowledge of peoples’ needs and risks, this understanding comes mainly from the years of experience of working in the home. The care plans are not always compiled from assessments or used as a working tool to help monitor the care, goals and wishes. A member of staff who has been working at the home for 5 weeks, knew very little about the care plans. When asked how they were able to deliver appropriate care safely, said they were told by other staff what to do and how to do it. Throughout the inspection this staff was observed caring for people appropriately. The home keeps daily records, which includes a laminated card that describes peoples’ goals. This was introduced to encourage staff to write about goals being achieved. However, the records had very little information about goals being worked on or met. Many of the goals did not relate to assessments of need or peoples’ wishes. In response to a survey one staff member said, when asked about what the home does really well “look at new goals for service users and help them achieve them”. The manager has introduced key worker meetings, this is to help staff understand their responsibilities as key workers and plan future care. The organisation has developed new care plan records which the manager hopes to implement once the staff have received training on how to complete them. The manager holds monthly house meetings to ensure the people living in the home are happy with the services they receive. These meetings are not entirely successful for everyone due to communication difficulties. The manager is introducing more one-to-one sessions with some people and using different communication methods. This will hopefully form part of the home’s quality assurance system to check with the people living in the home that the services they receive are satisfactory. Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 13 Lifestyle
The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 (Adults 18-65) and 10, 12, 13 & 15 (Older People) Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service.
Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 14 People are treated respectfully and supported to make choices about their lifestyles and maintaining relationships with families and friends. More activities or time spent with people when in the home would ensure there is more stimulation for people. People are provided with choices of well-balanced meals which they sometimes help prepare. EVIDENCE: Staff were observed and heard being kind and respectful to people throughout the inspection. Two people living at the home spoke fondly of the staff, one said “the staff are so kind, they help with lots”, another said “they make me laugh, I like being with them”. Relatives who responded to surveys said “the staff team are so caring”, “I’m so impressed with the care”. Care managers’ responses indicated they felt the home involved people in decisions and met peoples’ needs. Some people spoken with talked about how staff support them to maintain contact with family through visits, telephone and letters. Relatives also confirmed their in response to the commission’s surveys. The staff were very motivated to ensure people were given the opportunity to go out when they wished and experience activities and social events that met their needs and wishes. A timetable of activities was displayed in the dining room. Activities ranged from going to church each week, trips out to clubs in the evenings, swimming, pubs, educational groups, art & craft sessions in the home, shopping, lunches, cafes, picnics out and many more. However, due to staffing levels in the main house (3 for 9 people), only one or two people can go out at any time. In addition, staff have laundry duties to complete and meals to prepare. This means that much of the time many people are left sitting in communal rooms with no stimulation. During the inspection, one person was continually wondering and seeking attention from staff. The manager has recognised this and has introduced some extra hours per-week to provide one-to-one time for one person. The manager also intends to discuss this at a staff meeting to encourage staff to do things with people in the home when they are not out on activities. In the annexe, one person already receives one-to-one time. People spoken to said the meals in the home were good and said they were offered a choice of what to eat. Menus showed a well-balanced diet is provided. The menus are not in a format that suits every persons’ communication needs but staff said they talk to each person telling them what choices are on offer
Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 15 that day. During breakfast people were observed choosing a range of their preferred foods, for example, one person had beans of toast and had another cereal. Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support
The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 (Adults 18-65) and 8, 9 & 20 (Older People) Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Peoples’ dignity and privacy is fully respected and people benefit from their health needs being closely monitored. Medication practices are good and but some minor improvements are needed to fully protect people’s health & welfare. EVIDENCE: People living in the home said staff treat them kindly and are always respectful. Peoples’ files provide staff with good information about how they prefer to receive their personal care. Throughout the inspection staff were seen
Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 17 and heard to be respectful. The ethos and atmosphere of the home is very much about giving people choice, respecting their rights and providing a relaxed and respectful atmosphere. Staff had a gentle, caring and respectful manner when talking about the people living in the home and when communicating with them. Records provide good information about health needs being assessed and closely monitored. Staff demonstrated a good understanding of peoples’ health needs. Staff gave examples of how they were closely monitoring one person at the moment who they felt was “not their usual self”, Advice from health professionals had been sought and tests and monitoring were being carried out. One comment from a GP said “staff always appear very caring and well informed about current conditions. Relatives who responded to surveys felt health needs were “very well met”. One care manager said “the home has up to date health records”. People spoken to during the inspection said staff always supported them to attend health appointments such as the doctor or dentist. All staff (apart from new staff) have received training on the safe administration of medicines. The manager is also assessing staffs’ competences to ensure what they have learnt, they are also putting into practice, therefore protecting peoples’ welfare. Medication in both the main house and the annexe is stored appropriately. Medication is supplied in a monitored dosage system, with some boxes and liquids. Medication administration sheets had the occasional missing signature. Codes for when someone refuses medication were not always been used. Handwritten entries on the administration sheets did not always have double signatures. This would ensure two staff have signed to say they have checked to say the entry is correct, therefore protecting peoples’ health and welfare. Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection
The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 (Adults 18-65) and 16, 18 & 35 (Older People) Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. People living at the home are assured they are listened to and complaints are dealt with appropriately. There are good systems in place to ensure people are protected from abuse. Systems to double check some financial transactions will further ensure people are fully protected from financial abuse. EVIDENCE: Two people living at the home said the staff in the home always listen to them and act on any issues they have. They also said they would talk to the manager or their “welfare officer” if they were unhappy. One said the home also has meetings where they can raise concerns. Relatives who responded to surveys said they have never had to complain but felt confident that any issues would be dealt with quickly. The home has a complaint’s procedure in a pictorial format, which is kept in the hallway. The manager intends to remind the people living at the home of its existence at the next house meeting.
Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 19 The majority of the staff team have received training on the protection of vulnerable adults. The home has Adult Protection policies and the local alertor’s guide for reporting abuse. The staff demonstrated a good understanding of recognising different types of abuse and knew what to do if they suspected any. Southern Cross act as financial appointees for some people living in the home, peoples’ monies are paid directly to the company. The manager requests cash for individuals when necessary and maintains good records. Often money is given to people to spend as they wish. This means there are no receipts. It was agreed that on these occasions it would be a better and safer practice to ensure that either two staff witness the handover of this money, or the person receiving the money signs along with the staff. No financial statements were available to audit on this occasion. Other people living in the home have there own bank accounts. Staff support them to manage their monies appropriately. Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 20 Environment
The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 (Adults 18-65) and 19 & 26 (Older People) Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The environment is clean, homely and safe and meets people’s needs. EVIDENCE: Three people living in the home were proud to show their bedrooms. One said they did not like the colour of the room and had not chosen it. They said it was decorated by the previous provider and said they were not consulted about the
Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 21 colours. This person said they would discuss this with the manager. When we discussed it with the manager, she said the person had never raised it before but was happy to arrange for a change of colour scheme. Other peoples’ bedrooms were comfortable and decorated to individual tastes and preferences. The remainder of the house was clean and comfortable. The home has a conservatory next to the dining room and kitchen. The majority of people sit in the conservatory. Throughout the inspection only one person used the lounge. The manager felt this was partly caused by the dated décor and also because the lounge was away from where most of the staff are, which is around the kitchen area. The manager hopes to re-decorate the lounge bearing in mind the mixes of age groups when considering the decoration and furnishings. The conservatory has a range of appropriate seating which meets the physical needs of most people. One relative who responded to a survey said “the home gives residents a clean, comfortable and bright place to live”. A care manager said “residents are able to go to their own rooms when they need privacy. Most residents seem to congregate in the conservatory which can seem rather busy and noisy”. On the day of the inspection the home was tidy and clean. The home employs a cleaner five mornings a week. Laundry is carried out by the care staff and the people living in the home. The outside space has been made safer by better lighting and even surfaces on paths. Fencing has been replaced around the garden making it safer and more attractive. Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 22 Staffing
The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 (Adults 18-65) and 27, 28, 29 & 30 (Older People) Quality in this outcome is excellent. This judgement has been made using available evidence including a visit to this service. People are supported by enough caring, experienced and excellently recruited staff meaning peoples’ needs are met safely and they are protected from potential abuse. EVIDENCE: People spoken with felt there was enough staff on duty to meet their needs. One person has one-to-one support and another has recently had some hours allocated to one-to-one care. The manager said this will enable this person to go to the pub or choose an activity where they can be supported well. On the
Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 23 day of the inspection three staff were spoken with, one staff was fairly new. It was clear that all staff had a good knowledge of people’s needs. In the annexe one to one support is provided to ensure the complex needs of one person can be met safely and meaningfully. All staff have received a good range of training that helps them to understand and meet peoples’ needs, examples include, mandatory health & safety training, protection of vulnerable adults, medication administration, epilepsy, safe holding techniques, total communication and many more. One staff spoke about completing training to become a trainer in preventing and managing complex behaviours. This will ensure all staff in the home will be trained which will help them support people with complex needs. The organisation has produced a detailed induction booklet for new staff to work through. The manager said the standards are in line with the Learning Disability Award Framework (LDAF). These are standards expected within learning disabilities services. The knowledge gained from this induction will help staff towards achieving National Vocational Qualifications (NVQ). This is a national recognised qualification where staff have reached the standards of care expected in care homes. Information prior to the inspection indicated that over 50 of the staff team have achieved NVQ level 2 and others are in the process. The recruitment practices were found to be good ensuring the correct checks, including police checks (CRBs) are completed before someone starts working at the home. This ensures people are protected from potential abuse. During the recruitment process one person living in the home forms part of the interview panel. Informal interviews are also held with other people living in the home and with staff on duty. Candidates share a cup of coffee with everyone, get introduced and spend time with people. The manager then receives feedback from everyone and will only accept candidates if everyone feels they are suitable. Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 (Adults 18-65) and 31, 33 & 35 (Older People) Quality in this outcome is excellent. This judgement has been made using available evidence including a visit to this service. People live in a safe home that is run in their best interests. There are excellent systems in place that review and improve the service.
Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 25 EVIDENCE: Staff and the people living in the home spoke highly of the manager. One person living in the home said “she always sorts things out for me”, another said “I like her, she listens to me”. Staff said the manager provided good leadership and direction. This was observed throughout the inspection. A relative who responded to a survey said “I am really impressed with the skills, care and experience of Karen Farrelly and her team of ladies”. The manager has many years of experience of being a registered manager at another care home. She has obtained the registered manager’s award and NVQ level 4 in care. The manager has good methods of ensuring the home is run well and in peoples’ best interests. House meetings are held for the people living there, team meetings and key worker/ senior meetings are held for staff. These meetings ensure that peoples’ views are sought on how the home is run. They also ensure staff are clear about the work that is needed to improve the services. The manager also completes a quality audit for the organisation each month. This assesses areas of health & safety, environment, people living in the home, administrative work, staffing, training, recruitment, complaints and many more. Once completed, depending on the answers, produces a score. This scores provides the home with a percentage, if below a certain percent, the home has to produce an action plan for improvement. The manager was able to show an action plan for improvement that included time scales and people responsible. This ensures the work is carried out and within a reasonable time. Relatives views are also sought on how the home is run through annual questionnaires, the manager said these were due to be sent next month. A system to seek the views of the people living there, other than meetings, are currently being considered. Care plan reviews are held with care managers, the person the review involves, relatives, where possible and the staff team. Staff training and supervision ensures staff are trained and supported to deliver appropriate and consistent care. The fire logbook was found to be up to date and accurate. Fire risk assessments are up to date, staff training was completed, therefore protecting peoples’ safety and welfare. The home has recently had an environmental risk assessment audit completed by an outside company. The home is currently working through the recommendations made. Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 26 A questionnaire was completed by the manager prior to the site visit. This provides information about the people living in the home, staff, and fees and indicates whether necessary policies are in place. The information helps the commission prepare for the inspection and send surveys to appropriate people. It is also used to help the commission form a judgement as to whether the home is being run appropriately and safely. In this instance this information, the site visit and responses to surveys indicates the home is being run well. Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 27 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT Standard No Score 37 4 38 X 39 4 40 X 41 X 42 3 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 3 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Windsor Lodge Score 3 3 2 X DS0000063309.V335840.R01.S.doc Version 5.2 Page 28 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. 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 YA6 Good Practice Recommendations Peoples’ care plans should include peoples’ needs, wishes and goals formed from initial assessments. They should be recorded consistently and daily records should reflect if goals are being met. The home should consider “activities” in the home that include more time spent with people living in the home. Handwritten entries on medication charts should be checked and signed by two staff to ensure entries are correct. Where people refuse medication, appropriate codes should be recorded consistently. Where people receive cash that is held by the home, staff should ensure two people witness and sign to say it has been given. 2. 3. YA14 YA20 4. YA23 Windsor Lodge DS0000063309.V335840.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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