CARE HOME ADULTS 18-65
Windsor Road Mental Nursing Home 30 Windsor Road Ansdell Lytham St Annes Lancashire FY8 1AH Lead Inspector
Vivienne Morris Unannounced Inspection 23rd May 09:30 Windsor Road Mental Nursing Home DS0000006092.V330732.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 Road Mental Nursing Home DS0000006092.V330732.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 Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Windsor Road Mental Nursing Home Address 30 Windsor Road Ansdell Lytham St Annes Lancashire FY8 1AH 01253 731424 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) 01253 731114 Richmond Fellowship Mrs Kirsten Sharrock Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 10 individuals with severe and enduring mental health needs not liable to be detained under the Mental Health Act 1983 - 18 years 16th March 2006 Date of last inspection Brief Description of the Service: Windsor Road Care Home provides accommodation for up to ten young adults presenting with an enduring mental health illness. The home is a purpose built establishment with facilities on two levels, the upper floor being served by a passenger lift. All accommodation is offered in single bedrooms, two of which provide bed-sit type facilities, including kitchen areas. All bedrooms have ensuite bathrooms with both bathing and shower facilities. However, additional assisted bathing and shower facilities are available if help is required. There are two lounge areas, one activity room plus a conservatory leading to a wellmaintained rear garden. The home is situated in Ansdell, near Lytham and is within a short walking distance of shops, churches, public houses and the beach. The home provides a range of services and activities for the people living there and staff are able to meet a diverse range of needs, led by a team of experienced managers. Placements at Windsor Road Care Home are block booked by the local Primary Care Trust. Additional charges are incurred for hairdressing, toiletries, activities, holidays and chiropody. Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The unannounced site visit to this service was conducted over one day during May 2007, which formed part of the key inspection process. During the course of the site visit, discussions took place with 3 people living at the home, as well as 2 staff members and the deputy manager. Relevant records and documents were examined and a tour of the premises took place, when a random selection of private accommodation was viewed and all communal areas were seen. Comment cards were received from nine people involved with the service and their feedback is reflected throughout this report. The information provided by the home on the pre-inspection questionnaire has also been taken into consideration when writing this report. The inspector ‘tracked’ the care of two people during the site visit, not to the exclusion of the other people living at the home. The total key inspection process focused on the outcomes for those living at Windsor Road, which involved gathering information about the service from a wide range of sources over a period of time. The Commission for Social Care Inspection had not received any complaints about this service since the last inspection. What the service does well:
The information gathered before admission to the home was detailed, providing staff with a clear picture of each individual, so that they were confident that the staff team could adequately meet the assessed needs of people moving into Windsor Road. The plans of care were very well written documents, providing staff with clear guidance about how the assessed needs of people living at the home were to be met and how people were to be supported to maintain their privacy and dignity. Residents had been involved in the care planning process and a review of care provided was conducted on a monthly basis to ensure that current needs were accurately reflected in the plan of care. People living at the home were individually respected and all were offered the same opportunities, showing that equality and diversity was an important aspect of life at Windsor Road. Residents were able to make decisions about their lives, with support as required, including being able to take everyday risks, enabling them to live as full a life as possible. The home values and seeks to reflect the diverse needs of people living at the home. A variety of external professionals had been involved in the care of people living at Windsor Road to ensure that their health care needs were being appropriately met. Activities were provided both in the home and outside, so that people were able to continue their leisure interests whilst living at the home and so that
Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 6 they were able to maintain links with the community. The routine of the home was flexible and aimed to allow residents their freedom and independence by enabling them to have some control over their lives. One person living at the home said, “I can go out to the shops when I want. Someone (staff) will come with me if I want them to”, and another stated, “I go to the pub and sometimes to a night club”. Visiting arrangements were in place to suit the needs of individual residents and advocacy services were accessed for those wishing to have an independent person to act on their behalf. Meal times were well managed and people were provided with a choice of nutritious balanced food to ensure adequate dietary intake. Meals were well presented to promote appetite and to aid in nutrition. Those requiring support with eating their meals were assisted in a gentle manner, whilst others were encouraged to eat independently. The complaints procedure was freely available within the home and it was also included within the service users guide so that people were given enough information about how did they could make a complaint should they so wish. Comment cards received from people living in the home showed that they would know what to do if they were not happy about any aspect of life at Windsor Road. The policies and procedures in relation to safeguarding adults were in accordance with the Department of Health guidance ‘no secrets’, so that people knew the procedure to take should an allegation of abuse be received by the home. The home was pleasantly furnished and decorated to a good standard and the premises, both internally and externally were well maintained providing those living at Windsor Road with a safe, clean, comfortable and homely environment in which to live. The home was pleasant smelling and effective infection control measures were in place to ensure that the health and safety of people was adequately protected. One person living at the home was proud to show me his room, which he had helped to decorate. Staffing levels were calculated in accordance with the assessed needs of people to ensure that adequate care was delivered. Recruitment procedures were in place at the home, which demonstrated that those living at Windsor Road were adequately protected. A detailed induction programme and a wide range of training courses had been provided for staff so that they were kept up to date with current policies, procedures and legislation and so that they were able to provide adequate care. Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 7 The home was well managed by competent people and a team of skilled staff, who together had completed a wide range of training so that they were able to deliver the care required by the individual residents. Those spoken to felt supported by the management of the home and told me that they were comfortable in approaching the managers if they had any concerns. The registered manager held relevant qualifications, had a lot of experience and was appropriately trained to manage the care home. Those spoken to felt supported by the management of the home. Systems were in place to ensure that the quality of service provided was closely monitored so that any shortfalls identified could be promptly addressed. The health, safety and welfare of residents was, in general protected by the policies, procedures and practices of the home so that any hazards, which could pose a potential risk, were minimised or eliminated. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by
Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 8 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 9 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 Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 10 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): 2. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of people had been thoroughly assessed before they moved into the home to ensure that the staff team could fully meet all their requirements. EVIDENCE: The care of two people living at Windsor Road was ‘tracked’ during the site visit to the home. The care records showed that detailed information had been obtained prior to admission in order to determine individual requirements; so that the service was certain that the staff team could meet the assessed needs of people admitted to the home. The assessments carried out before admission were conducted by people who held appropriate qualifications and had experience in caring for people with enduring mental health problems, so that assessed needs were clearly identified. Information had been gathered from a variety of sources before admission to the home so that external professionals were also involved in the care of people to ensure that all their assessed needs could be fully met. People wishing to move into Windsor Road were involved in the assessment process and they were able to spend some time at the home before making a
Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 11 final decision, so that they could meet other people living there and so that they could briefly experience what life was like at Windsor Road. The assessed needs of those admitted to the home were clearly recorded within the care plans so that staff were provided with detailed guidance as to how people’s needs were to be fully met. Records showed that periodic reviews of placements had been conducted to ensure that the home remained a suitable environment to meet the continuing needs of people living at Windsor Road. Staff were appropriately qualified and had also received specific training in relation to the category of people living at Windsor Road in order to widen their knowledge and improve their skills in caring for people with enduring mental health needs. Staff spoken to had a sound understanding of the needs of the people they were looking after, showing that they were competent to deliver the care, which was required. Staff also knew how to access the care plans, policies and procedures, which showed that they were able to obtain relevant information if they needed it. Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 12 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, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users’ needs were effectively planned, their rights were upheld and they were supported to make informed decisions about the routines of daily life. EVIDENCE: The care records of two people living at the home were examined. The plans of care had been developed with the individuals and were well written documents, providing clear, detailed guidance for staff about how individual needs could be met and how people could be supported to make decisions within their daily life. The information obtained before people were admitted to the home was transferred onto the care plans, which had been reviewed on a monthly basis or more often, if necessary, reflecting any changes in the care of people living at the home so that staff were aware of
Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 13 people’s current needs. The plans of care outlined any limitations that needed to be implemented for the safety of the people living at the home and others. The Pre-inspection questionnaire showed that the staffing hours were calculated in accordance with the needs of residents, so that adequate care and support was provided. The service users’ guide demonstrated that those living at the home were offered choices in relation to daily activities. The care records seen provided information about the preferences and choices of residents and the plans of care included details about individual social care needs and leisure activities with details of how people were supported to continue these interests whilst living at the home. Freedom of movement within the home was evident and those living there were able to access their own private accommodation and all communal areas as they wished. Six comment cards were received from people living at the home. Some of these indicated that they were always able to make decisions about life at Windsor Road; others stated that they were sometimes able to make such decisions and others did not respond to this particular question. The Pre-inspection questionnaire showed that policies and procedures were in place in relation to the six values of care, including choice, rights and independence so that staff were aware of the importance of supporting people in independent living and allowing them to make decisions about their life. The pre-inspection questionnaire showed that people managed their own financial affairs, as far as possible. One person had a trustee to do this on their behalf, to ensure that this individual’s finances were appropriately handled. The Pre-inspection questionnaire also showed that the manager did not act as appointee for people living at the home and that individual bank or building society accounts were kept for individuals so that people’s finances were adequately protected. This was supported by the policies and procedures of the home. Staff were observed allowing people living at the home to make decisions about what they wanted to do during the day and information available told people about access to the local advocacy services, so that people could be supported in making important decisions about their lives. At the time of the site visit one person living at the home had travelled to London in order to attend a national residents meeting and a weeks holiday had been booked for the following month for those wishing to participate, which showed that people were supported to join in activities both locally and further away, where possible. Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 14 Those living at the home were able to take responsible risks within a risk management framework, ensuring that they had enough information on which to base decisions. A wide range of risk assessments had been conducted on an individual basis and plans of care-incorporated information about potential risks to individuals to ensure that any risks were minimised or eliminated. The pre-inspection questionnaire showed that policies and procedures were in place in relation to missing persons and risk assessment so that staff were fully aware of their obligations in relation to people living at the home taking risks. Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 15 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): 12, 13, 15, 16 and 17. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Social and recreational activities were provided in accordance with residents’ expectations and the rights of people were upheld. Residents received wholesome food and the special dietary needs of people were met. EVIDENCE: The pre-inspection questionnaire showed that a variety of activities were provided, both in and out of the home and that educational courses were available, where required, demonstrating that people living at the home had a choice of leisure interests. It was established that people were supported in any activity that they wished to pursue, as the home worked very much on an individual basis, so that people could continue their own interests and pastimes whilst living at Windsor Road. One person living at the home told me that he enjoyed doing some gardening and was eager to show me the current competition of ‘grow the biggest onion’. Comment cards received from people living in the home indicated that there were activities arranged which they
Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 16 could take part in and those spoken to said that they enjoyed living at the home. Care records included detailed social care plans, which showed what people enjoyed doing and from speaking with people living at the home their recorded interests were followed through in day-to-day practice. The environment was very relaxed and friendly, with residents and staff demonstrating good, trusting relationships. Plans of care showed that people were encouraged to maintain links with the local community and comment cards received from those living at the home supported this information. At the time of the site visit several people living at the home went out to places of their choice. The deputy manager confirmed that the home had a good relationship with neighbours, who regularly attended the various events held at Windsor Road Care Home. The residents’ notice boards displayed a variety of activities both in and outside the home, demonstrating that people had the opportunity to attend organised activity, if they wished to do so. Care records showed details of family links and people were evidently encouraged to remain in touch with family and friends. It was established that one person went to stay with family at regular intervals and others visited their relatives periodically. The home supported people to build relationships, where possible and evidence was available that the home had managed to trace the relatives of one person on their behalf, where they had ‘drifted’ apart. Independence was evidently encouraged, with people living their own lifestyle, being able to do as they wish, within a risk management framework. The privacy and dignity of people were respected and both residents and staff had developed a good rapport with each other, which created a unique friendly, family atmosphere. Staff were seen knocking on bedroom doors before entering, or asking people living at the home their permission to enter bedrooms, giving the reason why this was necessary. People held keys to their own bedroom doors in order to promote privacy and to protect their belongings. Doorbells had been installed on the doors of the two flats in order to promote independence and allow people some control over their lives. The Pre-inspection questionnaire showed that those requiring special diets were catered for, including those from minority ethnic groups. It also showed that facilities were available for people to make snacks and drinks and that meals were served at acceptable intervals throughout the day. The Pre-inspection questionnaire showed that policies and procedures were in place in relation to food safety and nutrition and that people were offered a choice of menu. This was supported by examination of the menus, which were submitted to the Commission with the pre-inspection questionnaire and which showed that a good choice of well balanced meals were provided. At the time of the site visit a buffet lunch was served, allowing people to help themselves to the wide
Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 17 range of food available. I was informed that those living at the home were involved in planning, preparing and cooking the meals in order to promote a sense of belonging. Cold beverages were constantly available in the dining room, although it was clear that people could access hot beverages and snacks at any time, if they so wished. Comments received on the day of the site visit, in relation to food were positive. Those spoken to said that the food was good. One person living at the home said, “The food is always very tasty and the staff are all friendly”. It was pleasing to see the staff dining with people living at the home, when it was noted that people were involved in general conversation about everyday issues. People spoken to said that the routine of the home was relaxed and that they were able to get up and go to bed when they wanted to. One person said that there was always a choice of menu offered. Staff were seen offering people a variety of choices in relation to daily living and residents spoken to said that staff were very helpful. People living at the home were responsible for their own laundry and keeping their bedrooms tidy. Support was provided, where necessary so that people’s independence was promoted. The rules on smoking, alcohol and drugs were detailed and any incidents were clearly recorded in the appropriate places. Both smoking and none smoking lounges were available, so that people’s rights were upheld. The pre inspection questionnaire showed that policies were in place in relation to equal opportunities. This included an explanation of the six principals of care, including rights, fulfilment, independence and choice, showing that all those living at the home were given the same opportunities to make decisions and informed choices about their daily lives. Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 18 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, 19 and 20. Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of people living at the home were being consistently met and their privacy and dignity was always respected. EVIDENCE: People living at Windsor Road were seen to be treated well, their privacy and dignity being respected. People living at the home confirmed this. Staff spoken to were aware of people’s rights and the need to promote their privacy and dignity. Staff were seen knocking on bedroom doors before entering, which were fitted with locks, so that people could protect their belongings and so that they could have some privacy, should they wish to do so. It was evident that people living at the home had total control over their lives, with support available as required and it was nice to see that they were involved in the allocation of their key worker to ensure that people with similar interests, age and culture were ‘matched’ up. Both plans of care examined were very well written documents. This enabled staff to have a clear picture of people’s assessed health, personal and social care needs and how these were to be appropriately met.
Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 19 The pre-inspection questionnaire showed that a wide range of external professionals were involved in the care of people living at Windsor Road and care plans examined supported this information. All comment cards received from people living at the home showed that they were satisfied with the care provided for them and two comment cards received from external professionals provided positive responses. One stated, “An excellent facility. Residents appear to be genuinely respected and treated with understanding and dignity. Staff are receptive to taking on local specialist advice and incorporating this into care plans”. The pre inspection questionnaire showed that medication policies and procedures were in place, so that staff were constantly aware of current regulations and guidelines in relation to the safe administration of medications. The management of medications had improved since the last inspection. Detailed assessments had been conducted for those wishing to administer their own medications and strategies had been introduced so that any risks identified were minimised. Clear medication records were maintained to ensure that a thorough audit trail was evident and photographs were retained of each resident on their Medication Administration Records for identification purposes. The pre-inspection questionnaire showed that registered nurses were responsible for the administration of medications so that people trained to do so gave those living at the home their medicines. It was evident that the three recommendations made at the last inspection, in relation to medications, had been addressed. Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 20 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints were well managed and people living at the home were adequately safeguarding against abusive situations. EVIDENCE: All comment cards received from people living at the home indicated that they would know who to speak to if they wish to make a complaint. A system was in place at the home so that any complaints received could be recorded and any recurring patterns identified and regularly monitored. The Commission for Social Care Inspection had not received any complaints about this service since the last inspection. The Pre-inspection questionnaire showed that poicies and procedures were in place in relation to complaints and concerns and these had not been changed since the last inspection, so information provided to people about making a complaint remained the same. The complaints procedure was clearly displayed within the home and was included within the statement of purpose and lease agreements, both of which were provided to people on admission to the home, so that people were aware of how to make a complaint, should they wish to do so. The pre-inspection questionnaire showed that there had not been any changes in the policies and procedures in relation to safeguarding adults since the last inspection, showing that information provided to people remained the same.
Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 21 Records showed that staff had been provided with abuse awareness training since the last inspection to ensure that they would know what to do should any allegations of abuse be received by the home in order to protect the people living there. Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 22 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People lived in a homely, comfortable and safe environment, which was clean, hygienic and well maintained. EVIDENCE: Windsor Road is a purpose built Care Home and is designed to meet the individual and collective needs of people living there. Furnishings, fittings and decoration were of a high standard, so that people living at the home benefited from a comfortable and homely environment. All comment cards received from people living at Windsor Road indicated that the home was generally fresh and clean. The pre inspection questionnaire showed that a bath in and en-suite facility had been replaced with a shower to suit the needs of the individual living in that particular room. The lounges and foyer area had been redecorated and refurbished with good quality furniture and the upstairs kitchen had been redeveloped, showing that a programme of routine maintenance was in place.
Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 23 The bedrooms were arranged like bed-sits, which were individually decorated and furnished, providing people with personal surroundings in which to live. Some people living at the home told me that they had been able to choose the décor of their own rooms and one person said that he had helped to decorate his bedroom, showing that people were encouraged to exercise choice. Two flats were available in order to promote independent living for those preparing to return to the community. Records showed that regular checks of the building took place, so that any work needed was promptly attended to. The home offers good access to local amenities, so that people living at the home can walk freely to shops, churches, pubs and the beach. Bed sits and flats were spacious, being tastefully decorated, furnished and individualised with people’s own belongings in order to create a homely atmosphere. All those spoken to were more than happy with their private accommodation. At the time of the site visit the home was found to be warm, thoroughly clean and pleasant smelling, providing people with a comfortable and homely environment in which to live. Comment cards received from those using the service stated that the home was generally fresh and clean. Infection control policies and procedures were in place and staff confirmed that they received appropriate training to ensure that the risk of infection was minimised. Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 24 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, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Not all staff working at the care home were appropriately trained. However, the numbers of staff on duty was sufficient to meet changing needs of residents and the recruitment procedures adequately safeguarded those living at the home. EVIDENCE: At the time of the site visit there were 10 people living at Windsor Road Care Home. The duty rota showed the grades and number of staff on duty at any time of the day or night, demonstrating that enough staff were deployed to meet the needs of the people living at the home. Residents spoken to felt that the staff team adequately met their needs. The Pre-inspection questionnaire showed that a variety of training programmes were provided for staff and that training had been planned for the coming months, including a wide range of mandatory courses. However, the Preinspection questionnaire showed that only 20 of care staff had received a National Vocational Qualification at level 2 or above. The home should be
Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 25 working towards achieving a 50 ratio of care staff with a National Vocational Qualification so that the collective work force is better trained as a whole. The Pre-inspection questionnaire showed that Criminal Record Bureau disclosures had been completed for staff employed by the home and this was supported by the examination of two staff files at the time of the site visit. The files seen were very well organised, showing that a thorough recruitment procedure had been adopted by the home. . One comment card received from a relative stated, “Very few staff have mental health skills or training”. However, the pre inspection questionnaire showed that 7 nurses employed by the home held a mental health qualification and records showed that a good skill mix of staff made up the staff team so that residents’ needs were being fully met. Confirmation had also been obtained from the Nursing and Midwifery Council to verify that the registered nurses working at the home were eligible to practice. Equal opportunity policies were in place at the home to ensure that everyone applying for work were treated the same and were given the same job opportunities. Training was provided for all staff specifically in relation to equal opportunities to ensure that they were aware of the importance of treating everyone the same, despite diverse needs. Formal induction processes had been adopted by the home so that staff understood their role and were able to perform the duties expected of them. Staff were supervised on a regular basis and staff appraisals were conducted periodically to ensure that those working at the home were encouraged to continue their personal development and to update their knowledge and skills. Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 26 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, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed by a competent person, having effective systems in place for monitoring the quality of service provided. The health, safety and welfare of people living at the home were, in general protected. EVIDENCE: The manager of Windsor Road is a first level registered nurse, with a specific mental health qualification and has had many years of relevant experience. She has been managing Windsor Road on a day – to – day basis for a period of 9 years and has achieved the registered managers award. Records showed that she continued to update her own skills and competence whilst managing the care home. This demonstrated that she was competent to manage the care service and was able to educate her staff team, so that the outcome for those living at the home was positive. There were clear lines of accountability within the home so that the service was successfully managed and a good quality of
Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 27 life was provided for those living at Windsor Road. Staff spoken to felt very supported by the management of the home, demonstrating that staff adopted a positive approach so that those living at Windsor Road had a good quality of life. There was a strong belief of being open and transparent in all areas of running the home so that people were kept informed of matters involving them. The management team were resident focused and the health, safety and welfare of those living at Windsor Road was evidently their priority. A variety of meetings had been held for staff and for people living at the home, from which notes had been made of the discussions, which took place, so that people were kept up to date with any relevant matters. Systems were in place so that the views of people involved with the service were obtained and any issues raised were discussed at the relevant meetings, so that any problems could be rectified. The pre-inspection questionnaire showed that systems and equipment within the home had been appropriately checked so that the health and safety of people living there was protected. This was confirmed by examination of a random selection of service certificates. However, the electrical installation was last serviced in 1998. According to the relevant certificate issued in 1998 it was recommended that the system be serviced in 5 years time. This period of time has lapsed and therefore the electrical installation should be serviced again to ensure that it is free from faults. Accidents occurring in the home had been accurately recorded so that the manager was able to audit and monitor the frequency of incidents. The pre-inspection questionnaire showed that 8 members of staff held current first aid certificates, so that any emergency situations could be handled appropriately. A wide range of risk assessments had been conducted, which were sufficiently detailed, showing that systems had been put in place in order to reduce the possibility of injury to people living at the home. The environment was free from any hazards, which could pose risks to those living at the home. Fire drills were conducted periodically to ensure that all staff were familiar with the fire procedure and evacuation plan within the home and a record was retained of staff attendance so that the home could ensure that all staff were involved in a fire drill at least annually. Staff spoken to confirmed that a range of mandatory training was provided, with regular up dates, showing that those working at the home were kept abreast of any changes. Policies and procedures were in place at the home in relation to Health and Safety issues, moving and handling, food hygiene and Infection Control Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 28 practices, so that staff were aware of the importance to ensure that the health, welfare and safety of people living at the home was consistently protected. Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 29 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 4 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 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 X 3 X X 2 X Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 30 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 YA32 Good Practice Recommendations The home should achieve a 50 ratio of care staff with a National Vocational Qualification at level 2 or above to ensure that the staff team are as a whole adequately trained. The electrical installation should be serviced to ensure that it is free from faults. 2 YA42 Windsor Road Mental Nursing Home DS0000006092.V330732.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way Preston PR2 2YQ 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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