CARE HOME ADULTS 18-65
Windsor Lodge 43 Cranford Avenue Exmouth Devon EX8 2QD Lead Inspector
Belinda Heginworth Unannounced Inspection 26th January 2006 11:15 Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 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.V279532.R01.S.doc Version 5.1 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 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.V279532.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Windsor Lodge Address 43 Cranford Avenue Exmouth Devon EX8 2QD 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.V279532.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th September 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 tend to run as two separate units. Networking Care Partnership are the providers of the home. Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four hours with the manager being present throughout. 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. Four staff were consulted and their views on the home were discussed. The inspector looked round parts of the building and grounds and a number of records were inspected. What the service does well: What has improved since the last inspection?
The manager has improved residents’ financial records by ensuring two people sign for all transactions. This therefore better protects residents from potential financial abuse. Recruitment practices have improved with evidence of full police checks, which protect residents’ welfare and safety. Risks to residents are reduced with detailed assessments highlighting the risk and clear action of what staff or residents need to do to reduce the risk. The administration and handling of medicines has improved by ensuring that the shelf life of some medicines is monitored. Staff now sign the records relating to medicines appropriately. This ensures that residents are better protected from being given out of date medicines or mistakes being made from poorly recorded instructions. Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 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 DS0000063309.V279532.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 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 the following standard(s): 5 Some improvements are needed to the admission practice to ensure residents receive information about the terms of living there. EVIDENCE: Residents are given a contract on admission. The contract is completed by the funding authority and provides limited information. 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. This was highlighted during the last inspection and has not been fully completed. Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 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 the following standard(s): 6&7 Residents’ privacy and dignity are met and promoted by the staff. However some improvements are needed in the decision making process. Improvement is needed in the care planning process to ensure that staff are aware of residents’ needs and goals. 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 working hard to come up with an easy to follow care plan and daily recording tool. The aim is to ensure that staff use care plans for information and to meet residents’ needs and goals effectively. Currently care plans are not used regularly and daily records have no reference to residents’ goals. It is therefore difficult to monitor any progress or changes that might be needed. Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 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 the following standard(s): 15, 16 & 17 The home is run in a supportive, caring and respectful way. Resident’s benefit from a healthy and varied diet. EVIDENCE: Residents who were able said that staff are kind and caring. They said that staff support them to maintain contact with their relatives and friends. Staff were seen being kind, patient and respectful. The atmosphere in the home was relaxed and full of laughter. Residents are offered a varied and healthy diet. Menus are displayed and residents who were able said that alternative food was given if they did not like what was on offer. Staff have a good knowledge of residents’ likes and dislikes, partly through a knowledge of the residents but also through information provided in the care plans. Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 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 the following standard(s): 18 & 20 Information is provided to staff that ensures staff are aware of the personal support residents prefer or require. Residents’ health care needs are well met but some improvements are needed to ensure staff are competent to administer medication. EVIDENCE: Residents’ care plans provide information to staff about residents preferred routines and how their personal or mobility care should be given. Staff demonstrated a good knowledge and understanding of such needs. This ensures residents’ needs are met safely. Most staff have received training on how to use the home’s medication system. The manager also carries out an assessment on new staff to ensure they are competent. The manager should carry out regular assessments of competencies on all staff to ensure residents’ safety and welfare is well protected. Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 22 & 23 Residents’ views are listened to and acted upon. Residents are protected from financial abuse but could be better protected with an improved monitoring system. EVIDENCE: Residents who were able said that staff listen to them and act on any concerns they raise. A recent disclosure by a resident was acted on appropriately and efficiently. The home has a complaints procedure, which provides clear information on what a resident or visitor should do if they have a complaint. Staff demonstrated a good knowledge of abuse awareness and knew what to do if they suspected any. During the last inspection it was highlighted that residents’ financial records were not kept in a way that was easy to monitor and did not protect residents from potential financial abuse. This has improved with a better recording system that includes two signatures for all transactions. The records are clearer making it easier to check spending and monitoring cash flow. However, the provider does not include financial monitoring during their monthly quality checks. This would better protect residents from financial abuse. Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 24 & 30 Residents live in a clean and pleasant environment. Improvements are needed to some areas to protect residents’ safety. EVIDENCE: The main house and annexe are bright, clean and cheerful with a warm homely atmosphere. Some areas outside of the home are unsafe to residents and look un-kept. For example, the fencing surrounding the house is broken in many places. From the outside the home is not welcoming and looks “scruffy”. The path leading up to the front door is poorly lit and is uneven. To the side of the house the concrete path and driveway is uneven. This means that residents cannot use these areas independently and staff said that the path to the front of the house is too dark to use at night. Until the work to improve these areas is carried out assessments of risk must be completed with clear actions of how to reduce any risks to staff and residents. During the last inspection it was highlighted that 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 had to be completed. This has been done the assessments state that the radiators are thermostatically controlled. This means that residents are protected from getting scalded from radiators that are too hot, however there is no mention of
Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 Page 14 the fact the radiators 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 DS0000063309.V279532.R01.S.doc Version 5.1 Page 15 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 &35 Residents are protected with the home’s improved recruitment practices and a competent and experienced team of staff, EVIDENCE: The main house has three staff on duty in the morning and two staff in the annexe. In the afternoon the main house and annexe have two staff. At night the annexe has one staff awake and one sleep in staff, the main house has one staff awake. Residents’ needs are therefore met. The manager hopes to improve this further by introducing a third staff on in the afternoons to enable more activities to take place in and out of the home. During the last inspection it was highlighted that some of the recruitment practices did not fully protect residents. For example full police checks (CRB), including POVA checks, were not completed and only one reference had been obtained before some staff started to work at the home. This has now been rectified with full CRB and references being obtained. Staff receive training that helps to protect residents’ safety and welfare. For example, fire safety, food & hygiene, manual handling, autism, epilepsy, medication and so on. Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 Page 16 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 Residents benefit from a well run home. Improvements are needed in the monitoring of the quality of services provided. EVIDENCE: Staff and residents spoke highly of the manager. Staff said she provided a clear sense of direction and leadership. It was clear throughout the inspection that the manager was working hard to raise standards and have better and clearer recording systems in place. For example improving care plans & risk assessments. The manager reviews the quality of services through a variety of ways. For example care plan reviews, staff training and supervision, monitoring the environment, talking to residents and relatives, providers’ monthly visits and so on. It was agreed that a formalised quality-monitoring plan must be completed. The plan must include what needs to be completed, with time scales and who is responsible. A copy of the home’s Quality Assurance plan must be sent to the CSCI. Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 Page 17 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 Standard No Score 1 X 2 X 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 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 OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 2 X 3 X 2 X X X X Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 Page 18 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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 accommodation to be provided for service users, including as to the amount and method of payment of fees. Timescale for action 28/02/06 2. YA24 23 (This refers to the fact that not all service users have terms and conditions and those who do are not up to date) This is repeated from the last inspection, some work has been completed but not all) The registered person shall 30/03/06 having regard to the number and needs of service users ensure that – (b) The premises to be used as the care home are of sound constructions and kept in a good state of repair externally and internally. (This refers to the fencing surrounding the home, the poorly lit path and the uneven surfaces outside) Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 Page 19 3. YA24 13 (6) 4. YA39 24 The registered person shall make 28/02/06 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 30/03/06 establish and maintain a system for – (a) Reviewing at appropriate intervals; and (b) Improving, The quality of care provided at the care home. (2) The registered person shall supply to the Commission a report in respect of any review conducted by him for the purpose of paragraph (1), and make a copy of the report available to service users. 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. 2 Refer to Standard YA6 YA7 Good Practice Recommendations Care plans should be used effectively and include residents’ goals and aspirations. Daily records should include information about the progress of such goals. Any decisions made on behalf of residents that might infringe on their privacy or freedom of movement should be discussed and agreed within a multidisciplinary approach. For example A Good Practice Committee. The manager should complete regular assessments of staff competencies in relation to medication. Where providers complete a monthly audit of the quality of services within the care home (Reg 26), an audit of residents’ finances should be completed.
DS0000063309.V279532.R01.S.doc Version 5.1 Page 20 3. 4 YA20 YA23 Windsor Lodge 5. YA39 The home should seek the views of service users, relatives and outside stakeholders on how well the home is run, as part of the home’s quality assurance audit. Windsor Lodge DS0000063309.V279532.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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