Inspection on 23/05/08 for Windsor Residential Care Home

This inspection was carried out on 23rd May 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Windsor Residential Care Home 30/05/07

Windsor Residential Care Home 05/09/06

Windsor Residential Care Home 23/12/05

Windsor Residential Care Home 06/05/05

Windsor Residential Care Home 16/08/04

Windsor Residential Care Home 16/04/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Windsor Residential Care Home 18-20 St Mildreds Road Westgate-on-sea Kent CT8 8RE Lead Inspector Nicki Dawson Unannounced Inspection 23rd May 2008 09:45 Windsor Residential Care Home DS0000023628.V363477.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 Residential Care Home DS0000023628.V363477.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 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 Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windsor Residential Care Home Address 18-20 St Mildreds Road Westgate-on-sea Kent CT8 8RE 01843 836055 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) windsor.house@craegmoor.co.uk Craegmoor.co.uk Parkcare Homes Ltd Carole Saunders Care Home 17 Category(ies) of Learning disability (17) registration, with number of places Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th May 2007 Brief Description of the Service: Windsor Residential Care Home provides residential care and support for up to 17 adults with learning disabilities. The home has recently been divided into two units, providing separate accommodation for 6 younger adults with a learning disability and 9 older people with a learning disability. The home is within walking distance of the Westgate-on-Sea. The local amenities include shops and the seafront. The train station is nearby and there are bus links to the surrounding towns. The home also has its own transport. Windsor Residential Care Home is part of Craegmoor Healthcare, which operates over 250 care homes. Information about the home, including reports from the Commission for Social Care Inspection (CSCI), will be made available on request. On the day of the inspection we were informed that the current range of fees is £786.12 to £914.52 Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection was unannounced, which means that the residents, staff and registered manager did not know that the inspector was calling at the home. The inspection started at 9:45am and took 8 ½ hours. Discussion took place with residents, staff and the registered manager, to gain their views and knowledge of the level of care, provided by the service. A number of residents have little speech so time was spent sitting with them at lunchtime, observing interactions with one another and the staff team. All shared areas of the home and resident’s bedrooms were entered. A number of records to do with resident’s care and safety were looked at. Prior to the inspection an annual quality assurance assessment (AQAA) was sent to the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Survey questionnaires (“Have Your Say About...”) were sent by the CSCI to the home for staff and residents to complete before the inspection visit. Two surveys from residents were returned. The people who live at Windsor Residential Care Home are referred to as ‘residents’ throughout this report since this is what they are called by the care staff team. What the service does well: Staff provide a homely and relaxed atmosphere. Residents, who are able to communicate, are able to make their needs known in a variety of ways. Through key worker meetings, resident meetings quality assurance questionnaires and at meetings with residents from other residential care homes in the company. Residents of all ages are encouraged to take part in independent living skills and more opportunities will be available now that the home has split into two units. All residents go on an annual holiday. The management style is open and inclusive, encouraging staff to be involved in the inspection visit. The recruitment of staff is carried out jointly between the home and the company making sure that all checks are in place before any member of staff is employed to work in the home. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Two resident bedrooms have an unpleasant odour, which is not in keeping with the expectation of the people who live in the home. One resident’s medicinal cream is not kept safely. It is kept in the resident’s bedroom where the resident could use it inappropriately. One care plan did not contain guidance on how to safely transfer a resident. Both the staff member and resident are at risk of injury if it is not carried out correctly. The registered manager has identified that residents have additional needs, but has not put a programme in place so that staff can be trained to meet these assessed needs. Activities that residents take part in are not recorded, so it cannot be certain that they take part in a range of stimulating activities. It can also not be certain whether they receive the correct amount of one-to-one support for which the local authority funds them. Residents still do not have a contract setting out their terms and conditions. Therefore, they cannot be sure of their rights and responsibilities. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 7 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 Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. People considering moving to the home are given all the information they need to help them decide whether or not to it is the right place for them to live. Peoples’ needs are fully assessed before they move into the home so that they can be sure that they will receive the right type of care. Residents are not provided with clear details of the terms and conditions of their stay at the home so cannot be fully aware of their rights and responsibilities. EVIDENCE: The aims and objectives of the home are set out in the home’s ‘Statement of Purpose’. The registered manager has recently updated the document to include the changes made to the environment. The services and facilities that are available to residents living in the home are detailed in the home’s ‘Service User Guide’. The guide is written in pictures to try and make it as easy to understand as possible for the people that live in the home. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 10 It is important that when a resident enters the home, their rights and responsibilities are explained to them, before signing a contract of their terms and conditions. At the last inspection a statutory requirement was made to update these contracts of residency and to give a copy to each resident. The registered manager could only find one resident contract that had been updated. This contract did not contain the resident’s room number or the date on which it was signed. The registered manager immediately printed off the new resident contracts. She assured the inspector that she would complete them and wherever possible explain the content to residents. The statutory requirement will not be re-iterated as a result of this pro-active approach by the manager. There have been no new residents admitted to home since the last inspection. On the last visit to the home, there was a new assessment procedure in place that is in keeping with a person centred approach that is used for care plans. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6-9 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from having a care plan that puts them at the centre of the plan. Residents are supported to make decisions and choices and to take responsible risks. EVIDENCE: The registered manager said that all residents care plans have now been updated to include person centred planning. This is an empowering approach to help people achieve their goals and live the life they want. Four plans were examined. The plans are written from the point of view of the resident. They clearly set out the health, personal and social care needs of each resident, together with the staff support that is required to meet these assessed needs. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 12 Each care plan is regularly reviewed and some plans have been identified as needing further updating. Written plans are in place to minimise the effect of potential risks to residents and these follow on from the assessed care needs. The moving and handling assessment for one resident stated to ‘follow transfer guideline pictures’. However, there were no pictures in the file and no written record of how staff should safely move the resident. The registered manager said that she would make sure that written guidance was in place until the picture guidance has been completed. Staff said that care plans are easy to understand. However, they cannot be used on a daily basis since they are very detailed and lengthy documents. The deputy manager said that she would review the care plans and look at summarising their content so that they can be used as a working tool. Care plans are person centred and focus on the individual choices of residents. The registered manager said that she is aware of local advocacy groups and gave an example of how she has used them to support the rights of an individual resident. Where monies are kept on behalf of residents, these are regularly audited to make sure that clear records are kept to safeguard residents. The registered manager says that she aims to involve the residents in home life as much as they are possible. Residents have regular meetings with their key workers. One resident has chosen to be involved in the recruitment of new staff by opening the door and being the first person that they meet, when they come to the home. The company promotes ‘Your Voice’ which identifies the importance of residents being listened to, to improve the service. Two of the residents from the home attend these area meetings. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11 - 17 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from the home being divided into two separate units so that activities can be offered according to their differing needs. Activities that residents take part in need to be recorded, so that the home can show that it is providing a range of stimulating activities for everyone. Residents are able to choose their meals and are offered a varied diet. EVIDENCE: On the day of the inspection three residents had gone to Broadstairs for lunch with two members of staff. Two residents were watching TV in the lounge and one in their room. The majority of residents were enjoying the sunshine in the garden. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 14 Each resident has a section in their care plan called ‘what I do’, which gives details of their weekly timetables of activities. In the four care plans that were looked at, activities include training for Craegmoor Olympics, reflexology, shopping, playing computer games, a visiting music man and attending a social club. The daily records for these residents, however, did not always contain details of what activities residents had actually taken part in. There is a section in each plan to record which activities are offered to residents on a daily basis and also for any one to one staff time spent with each resident. These sections had not been completed for any of the residents. Until this information is recorded daily, it cannot be certain whether residents are taking part in a range of stimulating activities. In the surveys returned from residents, one responded that they could do what they wanted to during the day and the other that they could not. Some care plans include a timetable for residents participating in independent living skills. After lunch residents were observed helping with the washing up. The recent home refurbishment has benefited all residents. Both parts of the home have their own kitchen and laundry room. The kitchen on the side of the home for younger people with learning disabilities has been refurbished to a good standard. The registered manager said that she intends to use it to promote resident’s independent living skills. The laundry room for younger adults is near completion and will enable residents to be supported to do their own washing. One resident said that they attend a local college. The registered manager said that she plans to look into further work and college opportunities for the younger adults who live in the home. Each care plan contains a section on communication, which is particularly useful for those residents who have limited speech. For example, it is recorded how a person lets you know that they are happy, by using words, or smiling or a certain behaviour. All residents go on holiday yearly and their last holiday was to centre parks. Relationships with family and friends are supported. There is a payphone in the entrance hall of the home that does not offer privacy. The registered manager said that residents are able to use the home’s hands free telephone to make private calls. Now that the home has been split into two units, meals can be tailored to the different needs and tastes of each group of residents. The older people with learning disabilities are to be provided with a four weekly menu. The younger adults are able to choose what they want to eat each week. Unfortunately, the cooker in the unit for older residents is not safe to use at present so all meals are being cooked in the younger adults kitchen. The inspector shared lunch with the residents. Residents’ chose their sandwich and if they wanted to sit inside or out in the garden. Staff joined residents for lunch and there was a relaxed atmosphere. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18-21 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be sure that their healthcare needs will be monitored and met. Residents’ safety is not always promoted, as staff do not always follow the home’s procedures for recording and keeping medicines. EVIDENCE: Residents personal support needs are recorded in their plans of care. It was observed that residents are able to choose when they get up and get ready for bed. On the day of the inspection, one resident got up just before lunch and another put on their pyjamas in the early evening to watch television. Care plans contain a section on ‘about my health’. Residents are supported to maintain their health by accessing health care services such as their GP, district nurse, optician and chiropodist. Residents have been on the waiting list for a NHS dentist for some time and now have access to this service. Healthcare visits are clearly recorded and show that appropriate action is usually taken. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 16 The home uses a pre-dispensed system for administration of medicines. This means that the majority of medicines arrive at the home in blister packs with the medication already measured by the pharmacist. This system is used to reduce risk of the residents receiving incorrect doses or incorrect medication. The person that is giving out the medicine then records on a pre printed form that the medicine has been given or, if it hasn’t been given, the reason why. On examination of this record it was found that it had been completed correctly, showing that medication had been given to residents as intended by their GP. A pot in the medicine cabinet contained some medication that is due to be returned to the pharmacist. However, the name of the medication had not been recorded. The member of staff on duty said that she knew the name of the medication, in line with the Pharmaceutical Regulation a record must be kept of all medicines returned to the pharmacist. A pot of medicinal cream was in a resident’s bedroom with no name on it. It is required that all medicines are named and kept safely in the medicine cabinet. The registered manager said that all staff, which administer medication, have received training in how to do this safely and that their competence to do so is regularly assessed. Staff spoken with said they feel confident that they have the knowledge and skills they need to deal with residents’ medication safely. Care plans contain a section, ‘when I become very sick or might die’. This contains information on the resident’s wishes such as whom they would like to be informed and any wishes after death. The amount of information in each plan has been completed according to the ability and comfort of the resident to make their needs known. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents feel that their views are listened. So that the home can improve for the benefit of residents, a record of all complaints received about the service should be kept in the home. Residents’ benefit from living in a safer environment. EVIDENCE: Information that the home gave us before the inspection was that they had not received any complaints since the last inspection. However, the commission has received one complaint about the home. This complaint was investigated by the company area office and not substantiated. The registered manager is aware of the compliant, but there is no record of the details of the compliant or its outcome at the home. The registered manager said that she would obtain the relevant information. The home has a complaints procedure, which explains how residents or others can make a complaint about any aspect of the service provided. This is written in a pictorial format in the service user guide. Surveys completed by residents confirmed that staff treated them well and listened and acted on what they said. One person responded that they knew how to make a complaint, but the other responded that they did not know who to speak to if they were not happy or how to make a complaint. The deputy manager said that she would speak to all residents at the next residents meeting, to make sure that they all Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 18 know who to talk to if they are unhappy about any aspect of their care or if they want to make a compliant. The two safeguarding adults investigations by social services that started before the last inspection have now been concluded. The registered manager said part of the outcome of the investigations was to split the home into two units so that the more vulnerable adults in the home are protected. Staff said that there is an open ethos in the home whereby they are confident in bringing any concerns about any care practice to the attention of a senior member of staff. “I definitely could tell Carole or Sarah (deputy manager) said one member of staff”. The registered manager said that all staff attend formal training in safeguarding vulnerable adults annually. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 - 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from changes to the home environment which enable the younger residents to be more independent and the older residents to remain safe. Residents’ dignity is not always maintained, as they are not all provided with bedrooms, which are free from offensive odours. EVIDENCE: There have been major improvements to the environment since the last inspection. The home has been separated into two separate units. This is so that more specialised care can be provided focussing on residents individual needs. One unit is for younger adults with learning disabilities, the other unit is for older, more vulnerable residents, some of whom have limited speech and communication skills. Both units have a lounge, kitchen and laundry room. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 20 All residents bedrooms apart from two have been re-carpeted and newly decorated according to residents’ individual tastes. Many also have new furniture. Residents have been given the opportunity not to share a room and only one shared room remains, which the registered manager said is shared due to the wishes of the both residents. The younger adults are provided with one shower room. Two residents have ensuite facilities in their bedrooms. The older residents are provided with a shower room with a chair for those with limited mobility and a bathroom with a hoist. One older resident has an ensuite room. New bathrooms have been provided with grab rails for the less able. There is a shaft lift providing residents access to all floors in the older persons unit. During the refurbishment the doors of two residents bedrooms have been widened to make it easier for people using wheelchairs. There is a garden to the back of the home, which has a patio area with chairs and tables so that residents can eat their meals outside in fine weather. Currently residents share this outside area, but the registered manager said that there are plans to divide the garden into two separate areas. There are three areas where the environment of the home is not maintained to the same high standard as the other areas of the home. Firstly, two bedrooms had a smell of urine. One room is due to be redecorated next month. However, the other room has been newly decorated and staff said that it is regularly cleaned. The registered manager said that a more thorough cleaning programme would be put in place to make sure that the room is fresh and hygienic. Secondly, three newly decorated rooms were not up to the same high standard as the other refurbished rooms. One had a rip in the floor covering that poses a potential risk of someone tripping; one had a broken door on a vanity unit and in another there was a watermark on the ceiling. The registered manager said that the floor covering and vanity unit would be replaced. She explained that she has already had the ceiling looked at and there is not a water leak. However, she will have the ceiling checked again to make certain that it is safe. Thirdly, the door to one bedroom was being wedged open. This would not help prevent the spread of a fire if it occurred in the home. The registered manager said that she would order a devise that could be fitted to the door so that it would automatically shut in the event of a fire. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 21 The home was clean on the day of the inspection. Surveys received from residents confirmed that the home is always clean. Staff demonstrated that they know how to minimise the spread of infection in the home. The registered manager confirmed that most staff have had formal training in this area. There is a sluice facility situated in one of the units. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32 - 36 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. To make sure that residents’ current needs are met in a satisfactory way, staff need to be trained in the specialist areas that have been identified. There is a robust recruitment proceed for new staff so that residents are protected from potential harm. Residents’ benefit form a well-supported staff team. EVIDENCE: There are three members of staff on duty in each unit during the day. The registered manager said that when more new staff have been recruited the staffing levels should rise to four staff in the older persons unit. In addition there is cleaning staff and a maintenance man. One third of the staff team have left their employment at the home in the last year. The registered Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 23 manager said that the majority of these staff were from overseas on shortterm contracts. 23 of staff are trained to National Vocational Qualification (NVQ) level 2 or above. Seven staff are currently working towards level 2. When these staff complete their training over 50 of staff will be trained to NVQ 2, which meets the National Minimum Standards. This award is useful because it helps staff develop good care practices and their skills in working with people who live in a residential care home. During the inspection staff were observed communicating with residents in an individual way. The registered manager is responsible for making sure that care staff have the skills they need to support the residents who live in the home. She said that all new care staff receive introductory training, which gives them the basic competencies they need to be able to work without direct supervision. The company has developed this training. The registered manager said that it covers all the areas that are required to meet the National Minimum Standards. Before new members of staff are employed at the home a number of checks need to be carried out to make sure that all members of staff working at the home are suitable to care for vulnerable residents. Files were seen for four members of staff. All the relevant checks and documentation including Criminal Record Bureau enhanced disclosures, two references, contract of employment and application form were included showing that the recruitment process followed protects the residents. In addition to the introductory training, care workers undertake a number of training courses that develop their skills in caring for the people that live in the home. Each staff file that was viewed contained individual staff training certificates. In addition, the registered manager has developed a staff training matrix for recording all staff training and alerting her when mandatory training is due that needs to be implemented. It was required at the last inspection that the registered manager identifies and put a programme in place for further staff training. The registered manager has identified that the staff teams in each unit need different specialist training such as diabetes, dementia and epilepsy, but has yet to put a programme in place. The registered manager believes that staff supervision is important but admits that she finds it difficult to sustain on a regular basis. Staff said that that they felt supported by the management team and files showed that they had recently had formal supervision. There are regular staff meetings. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from living in a home that is well managed. EVIDENCE: The registered manager has been employed in a social care setting for sixteen years. She has been the registered manager of Windsor Residential Care Home since October 2004. She has both of the formal qualifications specified by the National Minimum Standards. These awards are recognised by the commission to be useful because they help to make sure that people who manage residential care services have the competencies that are necessary to do so. She is also obtained the NVQ assessors award. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 25 The registered manager has a clear vision of they way that the home needs to improve to benefit the residents that live there. “Carol is easy person to go and talk to and will generally listen to what you say,” said one member of staff. Staff understand the aims and purpose of the home and most were positive about the change of the home into two separate units. For the home to run in the best interests of the residents it is important to have a system in place which regularly obtains the views of residents and visitors about the standard of care that they receive from the home. The company send out surveys to residents, relatives and staff every six months and feedback to the home. The registered manager said that the home has listened to people’s views about the service and as a result has provided a private room for visitors, which is also used as the staff sleep-in room. Regular audits are conducted within the home either by the organisation or the registered manager. These audits include health and safety, medication; person centred planning and infection control and residents finances. The registered manager said that all items of equipment in use in the home remain in good working order and the provided the dates on which they have been serviced. Fire records indicate that fire equipment is serviced and tested regularly. A new fire risk assessment and procedure has been drawn up due to the changes in the home environment. This means that the home is doing all it can to reduce the risk of a fire occurring in the home. However, as mentioned previously, one fire door is currently being wedged open which does not minimise the spread of a fire if it occurs in the home. There is a staff training matrix to identify the staff training needs of the whole team and this is going to be developed to include the specialised training that is needed for each staff team. Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 26 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 3 2 3 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 3 3 3 X X X 2 Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 27 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 YA20 Regulation 13 (2) Requirement The registered person must provide an action plan to the Commission setting out how they will :make arrangements for the naming, safekeeping and disposal of all medicines received into the care home. Timescale for action 07/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Windsor Residential Care Home DS0000023628.V363477.R01.S.doc Version 5.2 Page 29 - 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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