Inspection on 15/01/07 for Windward Way

This inspection was carried out on 15th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Windward Way 27/06/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group Pooley Heights

Maple Lodge

Maple Lodge

Polesworth Group 32 Station Road

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

CARE HOME ADULTS 18-65 Windward Way 170-174 Windward Way Smith`s Wood Solihull West Midlands B36 0PS Lead Inspector Key Unannounced Inspection 15th January 2007 09:45 Windward Way DS0000066539.V324784.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 Windward Way DS0000066539.V324784.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. Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windward Way Address 170-174 Windward Way Smith`s Wood Solihull West Midlands B36 0PS 0121 779 6059 F/P 0121 779 6059 mikeklymko@lonsdale-midlands-limited.co.uk enquiries@lonsdale-midlands-limited.co.uk Lonsdale (Midlands) Limited 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) Nicola Jane Doughty Care Home 12 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (1), Learning disability (12), Physical disability of places (12) Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service may continue to accommodate two named service users within existing numbers who have learning disabilities with added dementia needs. 27th June 2006 Date of last inspection Brief Description of the Service: 170-174 Windward Way consists of three adjacent, domestic style bungalows. Each bungalow has four single bedrooms. The homes are located a residential area of Smiths Wood, a suburb of Solihull and provide care and accommodation to twelve younger adults with learning and physical disabilities. The home has a variation of registration for two service users are above the age of 65 years to enable them to remain in the home. Local amenities including Woodland Parks, and shops are within walking distance. Chelmsley Wood shopping centre is approximately one mile away. Each home has a communal lounge, kitchen/diner, assisted bathroom, separate toilet, and four single bedrooms. Bedrooms vary in size and layout; there are no en-suite facilities. Each home has an individual area of garden at the rear. These are generally well maintained, although not well suited to the needs of people with impaired mobility. The sloped grassed area of bungalow 174 is not safe for use by wheelchair users and others who have restricted mobility. There is an adequate supply of lifting aids and pressure relieving equipment in each bungalow. The layout of each bungalow are virtually the same, there is no dedicated rooms for storage of large equipment. Although the premises have assisted bathing facilities they are inadequate for the degree of physical disabilities that some service users have who are currently living at the home. Lonsdale (Midlands) Limited are the registered providers. The charges are £900.00 per person per week. Chiropody, hairdressing and papers/magazines are of varying prices and are not included in the fee rate. Lonsdale allocate funding to each service user for payment of activities and outings. Activities are considered to be an important aspect of service users lives; these are tailored to each individual’s preferences and are reviewed weekly. Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork visit was carried out over a period of one day. The manager throughout the visit provided assistance. There were twelve service users living at the home, there have been no vacancies for a considerable period of time. Information was gathered from speaking with a resident who could hold a meaningful conversation and from spending time with other service users. Staff were also spoken with and they were observed whilst carrying out their duties and communicating with service users. A sample of four care plans were seen, these included one from each bungalow. The arrangements for health and safety and medications were reviewed. Progress made against the requirements generated from the inspection of 27th June 2006 was checked. Staff files and training were looked at. A tour of the premises included some bedrooms and all communal rooms in each bungalow. At the end of the visit verbal feedback was given to the manager who advised that she has a good staff team and she was committed to continuing to make improvements. No Immediate Requirements were left at the home. What the service does well: Staff show knowledge of service users needs and were able to communicate with them by interpretation of sounds made and the use of body language. Pictures are also used to enable staff to understand individual’s needs and preferences. Encouragement and support is provided to promote service users quality of life by maintaining their relationships with families and friends. Service users receive personal care according to their needs and preferences. Care plans indicate that a proactive approach is used towards healthcare needs to promote service users health and well being. The staff have been employed for a considerable length of time, the home has not needed to recruit staff. During staffing shortages bank staff are asked to cover shifts and agency staff are rarely used as a last resort. This provides continuity of care for service users and a workforce who are familiar with their needs. Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 6 Some service users have tracking hoists in their bedroom to improve the methods of transfers to and from bed to wheelchair. For those service users who have no family the home enlists the help of advocates to enrich their lifestyle. Service users hold a meeting in each bungalow every Sunday when they decide on the food menu and activities for the following week. If a chosen activity is not on their normal weekly rota staff make the necessary arrangements to ensure that requests are met. This promotes a varied lifestyle and assists service users in meeting their objectives. What has improved since the last inspection? What they could do better: Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 7 Bathing facilities are not appropriate to cater for the physical disabilities of some service users. One service user said, “I have a shower because the bath is no good for me”. A review of staffing levels for night duty is needed, which takes into account personal needs, physical disabilities, how service users are monitored during the occasions when staff double up to provide personal care. Further considerations should include the preferences of service users who may wish to retire beyond 22:00 when there is a reduction of available staff and how night staff are able to take their allocated breaks. The home needs to demonstrate that service users preferences and personal care needs are being fully met. The kitchen units in bungalow 172 are in need of repair or replacement to improve the facilities for staff and appearance for service users. 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. Windward Way DS0000066539.V324784.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 Windward Way DS0000066539.V324784.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, 2,3 and 5. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose does not supply prospective service users or professionals with sufficient details for them to make an informed decision about the home. The home demonstrates that it is able to meet indentified needs by carrying out a comprehensive assessment and information is gathered before a placement is offered. Service users have not been made aware of their rights whilst living at the home. EVIDENCE: The statement of purpose does not include all of the required information. Details needed include the age group of service users within the registration, the number of staff, how care plans are developed and reviewed, the emergency evacuation procedure and advise of the existence of tailored evacuation plans for each service user. Each bedroom has a notice board containing a copy of the service user guide, the complaints policy and a picture of the allocated key worker. The manager advised that the home is working towards producing the documents in pictorial format. The home has not had an admission for a considerable period of time. The manager described the process that would be used. Actions would include an Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 10 assessment by a senior person, gathering of information from professionals, offer visits to include an activity and a meal followed by an overnight stay to ensure a phased process to enable the prospective service user to make an informed decision. The manager was informed that following assessment, confirmation that the home is able to meet the prospective service users needs to be supplied in writing. Contracts of terms and conditions of residency have not been issued to service users. This is due to the recent change of ownership. The home has not provided service users with information regarding their rights. Windward Way DS0000066539.V324784.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, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users know their assessed and changing needs are met They are consulted and encouraged by staff to lead an independent lifestyle. EVIDENCE: Care plans and risk assessments were sampled from each bungalow and one involving specific health care needs. The files were noted to be logically laid out and included ‘read and sign’ sheets to ensure that staff have knowledge of individual’s needs. It was pleasing to note that care plans and risk assessments were more detailed and clearly written in providing a whole picture of service users needs and how staff should deliver them. The files confirmed that the service user and/or relevant other persons such as family and external professionals are invited to attend and participate in the development and reviews of care plans. This is viewed as being good practice. Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 12 Service users were observed making choices about where to spend time and with whom. Meetings are held every Sunday in each bungalow when service users decide on the food menu and their activities for the following week. It was observed during the visit that different types of evening meals were being prepared. Socialising of service users in each other’s bungalows was being encouraged and was observed during the visit. This reflects freedom of choices. Service users require assistance with management of their personal monies. Records sampled showed that cash balances held on behalf of service users are included as part of the handover at the beginning of shifts. The balance sheets indicated that two members of staff carry out regular audits to ensure that accuracy is maintained and prevention of financial abuse. Windward Way DS0000066539.V324784.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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Varied indoor activities and outings are provided to meet service users expectations and enhance their quality of life. Service users are able to exercise choices about their daily routines and staff actively promote their independence. The written menu indicated that service users enjoy a wholesome, nutritious and balanced diet and choices are catered for. EVIDENCE: A copy of the individual activity plan is located in the care plan and on the notice board of the respective service users bedroom. These indicate that activities are tailored to reflect personal choices have been made. Pictures are used to assist service users in making decisions. Any requests of variation to the plan is organised by a member of staff. Service users responses to activities are recorded so that activities enjoyed are noted. Staff encourage and assist service users in carrying out household tasks such as cleaning their bedroom or participating with preparation of meals, which Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 14 they appeared to enjoy. Each bungalow has a large selection of indoor games. A service user was observed playing an electric organ, he was also observed mashing the potatoes for the evening meal. Since the last inspection three service users have commenced attendance at college. Another service user periodically attends church services and staff have identified that he enjoys the visits. The home has developed a positive relationship with the nearby school; service users are invited to use the schools hydro pool on Thursdays. The school also invites service users to events such as working in the woods, planting and planning meetings. Service users are supported in maintaining friendships and relations with their families and may go out shopping or to a pub with them. A service user said, “I have shandy when we go to the pub”. Some service users were accompanied by a member of staff in spending Christmas day with their family. There was evidence that service users have an annual holiday and are escorted by appropriate numbers of staff to ensure their needs and safety are met. Two service users regularly visit a boutique to have their nails painted. Some service users have their own computer as well as other equipment such as television, DVD recorders and music centres. It was obvious that recreation and independent living skills are an important element of service users lifestyle. The inspector was informed by a service user, “I go to college and do music and talking, I go to the gym, the trainer has done a programme for me”. Each bungalow was visited during lunchtime and it was pleasing to note that service users were eating a variety of light meals to suit their tastes. Service users confirm the menu for each bungalow during their Sunday meetings. The written menu provides two options for lunch and the evening meals. It was noted that different main courses were being prepared in bungalows for the evening meal. The meals being prepared were noted to be appealing and the written menu indicated that a varied, nutritious and balanced diet was being ensured. The home is able to cater for special diets. A service user spoken with said his favourite food were, “potato with cheese”. Windward Way DS0000066539.V324784.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, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive their personal care according to needs and preferences. Some healthcare needs are not always well managed, which could compromise service users well being. Staff practices in respect of administration of medications, ensures that service users receive their medications safely. EVIDENCE: Four care plans were reviewed. Each service user has a written care plan. This identifies the assessments carried out and the care needs that staff need to deliver to promote service users health and well being. Medical conditions and instructions for staff to provide care for the identified needs are clearly recorded. A separate file provides in depth details of the services of external professionals including the reason, outcome, guidance for staff and required monitoring to ensure that health needs are being met. Care plans included a communication dictionary to enable the staff team to understand about service users personal preferences such when and mode of bathing and when they are in pain. Files indicated that some individual’s Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 16 preferred to bathe during the evening. One service user was noted to be having an afternoon sleep on a couch. It was observed that staff were very good at interpreting service user’s needs. Some shortfalls were found, which may compromise service users well being and choices: • A care plan concerning PEG feeding was not dated • A section regarding PEG feeding had not been signed by the author • A bowel movement chart had not been completed for seven days. It was not possible to ascertain if this was an oversight of staff recordings or if it was a true circumstance that staff had failed to recognise as being a problem • A service user said, “I have a shower because the bath is no good for me”. • It was found that all service users had to retire by 10pm when the last of the day duty staff left the home leaving one per bungalow. This restricts service users from making decisions about going to bed at a later time. It also questions how night staff are able to monitor service users on the occasions when two staff are needed to provide personal care. A service user said, “Staff are good to me”. Another service user expressed his satisfaction with standards of care by touching of hands. Medications were found to be securely stored. The system for receiving, and disposal of medications were found to be safe. Medications received were being appropriately audited. The medications for those persons whose care plans were seen were checked and found to be satisfactory. The process for medications ensures that service users receive their prescribed medications and they are safeguarded from potential harm. Windward Way DS0000066539.V324784.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that their views will be listened to and any complaints dealt with effectively. Staff knowledge and written procedures indicate that service users are protected from the risk of abuse. EVIDENCE: A copy of the complaints procedure is located in each bedroom and a member of staff asked a service user if he had any complaints and if so how would he make a complaint. He advised that he would make complaints to the key worker and expressed his satisfaction with the home. Efforts have been made by staff to present this information to service users in a format they can understand. The home has not received any complaints since the last inspection and none have been forwarded to CSCI. The manager informed the inspector that the home uses Birmingham or Solihull’s guidelines for prevention of and reporting incidents of abuse. The home also has its own policy, which was noted to be comprehensive and includes a flowchart for actions to be taken in the event of abuse or suspected abuse. There is also a written whistle blowing policy to ensure lack of victimisation of any person who may report incidences. Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 18 All staff have received training in adult protection and two staff demonstrated that they would take appropriate action when abuse is suspected. Windward Way DS0000066539.V324784.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, 25, 26, 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with warm and comfortable accommodation to promote their well being. The current bathing facilities prevents service users form making choices. An outstanding maintenance issue puts service users at risk of injury. EVIDENCE: 170-174 Wiindward Way comprises of three, four bedded bungalows, which are domestic in size and scale. Number 170 includes a staff office and staff sleep-in room of 174 has been converted to a staff room for storage of personal belongings. A sample of bedrooms were visited, as well as and the majority of communal areas. All lounges, hallways and bathrooms have recently been re-decorated and one kitchen has had new units installed. One bedroom was in the process of having built-in wardrobes fitted, a bedroom was also being re-decorated. Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 20 These practices serve to provide a fresh and welcoming environment for the benefit of the service users. The bedrooms seen were noted to be laid out in the manner preferred by the occupant and were very personalised. Service users are involved in choosing paint colours and are consulted when bedroom furniture is purchased. It was evident that service users had made decisions about what they wished to have in their bedrooms. Bungalow 174 does not have suited door locks, this needs to be addressed to ensure that privacy and dignity of those service users is maintained. Bathrooms provide limited assisted facilities for the benefit of those who are physically impaired. One service user advised that he is unable but would prefer to have a bath, he currently uses the shower. This restricts people from having their preferred means of bathing. The manager said that there are plans in place to refurbish bathrooms to enable choices to be made. Five bedrooms include specialist tracking hoists to improve assisted transfers to and from bed to wheelchair. A range of other lifting equipment was evidenced and pressure relieving items were also in place to prevent pressure ulcers from developing. A call system is in all bungalows and these are interconnected between each building. Each bungalow has a laundry room to include washing machine, tumble dryer and COSSH (Control of Substances Hazardous to Health) items are stored in a locked cupboard to prevent risks of injuries to service users. It was noted that none of the bungalows have designated storage rooms for unused equipment, which had been stored in the garden sheds. The kitchen units of bungalow 172 were found to be in need of repair and replacement. Some cupboards were in need of attention and one base unit door was missing. This detracts from a pleasing environment. Each bungalow has a rear garden with connecting gateways. They consist of lawn, paved paths and patio area, a garden shed and seating. The lawn of 174 has a significant camber and is not suitable for persons with restricted mobility especially wheelchair users. The camber poses significant risk of injury to service users, action needs to be taken to provide a safe environment. This remains outstanding from the last inspection and should be dealt with as a matter of priority. The contents of the unlocked garden sheds have been reduced but the contents still pose a threat of injury if accessed by service users. Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. Allocated day staff are in sufficient numbers to meet service users needs but during night time hours service users are not always supervised, which may impair their well being. Documents seen indicated that the home would carry out robust staff recruitment, which will protect service users form risks of harm. Some staff training is needed to provide them with the knowledge and skills to meet service users needs. EVIDENCE: Staff were observed communicating effectively and adopted a friendly and respectful manner to service users. Staff demonstrated knowledge of individuals needs and this was provided in a supportive manner, which was consistent with the care plans sampled. The duty rota indicated that with the previous amalgamation of residential and care staff that there was sufficient staff during daytime hours to meet service users needs, recreations and aspirations. Three night staff, one for each bungalow work from 8pm until 8am and one of the daytime team works until Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 22 10pm to assist service users in retiring. During staffing shortages the home has bank staff to call upon. Agency staff are rarely used, the home approaches the same agency to ensure continuity of care. The manager advised that service users are unable to retire later than 10pm because of the decreased staffing levels. This restricts people’s independence and rights to make choices. The physical needs of some service users require two staff to carry out personal care. Although staff can communicate via the call system or by telephone, there are periods when service users are unsupervised. The health needs of some service users require constant supervision; this is not being achieved during nighttime hours. A review of staffing for nights needs to be carried out, which takes into account, the dependency levels of service users and how staff are able to take their breaks. Upon completion of the review the organisation needs to take appropriate action to ensure the standards of care are being maintained. Staff were found to communicate well with each other and consulted with the manager regarding various aspects. This indicated positive teamwork and liaison in order to achieve the complex and varied needs and aspirations of service users. Since the new organisation took over in November 2005, the home has not recruited any new staff. Four staff files were seen, they revealed that the necessary checks on staff have been carried out regarding CRB’s (Criminal Records Bureau) and that support and guidance was being provided to enable staff to carry out their roles effectively for the benefit of the service users. It was noted from the training matrix that most staff have completed all mandatory training and other courses, which reflect the specialist needs of service users. More than 50 of staff have successfully achieved NVQ level 2 and some have enrolled to commence level 3 training. Staff inductions reflect the programme of Skills for Care topics, which ensures all aspects are covered to enable staff to adequate knowledge of their roles. Some shortfalls were noted, these included Health and Safety and Ageing and Dying. In light of the ages of some service users, training in Ageing and Dying is needed to enable staff to meet all the needs of those persons. Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 23 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 adequate. This judgement has been made using available evidence including a visit to this service. The manager is experienced and possesses the skills to oversee the day to day management of the home. Some maintenance issues and lack of staff training puts service users and others at risk of accidents and injury. EVIDENCE: The manager is a registered learning disability nurse and has considerable experience of management and working with people with learning disability and displayed motivation in continuing to make improvements for the benefit of service users. She is supported by a deputy manager. Observations of the manager and deputy manager indicated that there was a transparent approach to service users and delegated tasks to staff in a constructive manner. Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 24 Quality assurance systems were in need of development although it was reported that the home has made an application to undergo and achieve Investors in People award. The accident records are good and there was evidence of investigations and action taken to reduce risks where indicated. All relevant checks and servicing of equipment have been carried out within the necessary timeframe to ensure that they are fit for purpose. The fire alarm and emergency lighting systems are regularly checked and the findings recorded to protect service users from harm in the event of an emergency situation. The home has developed written individual emergency evacuation procedures, which takes into account the physical disabilities. All hot water outlets that service users come into contact with are regularly checked and recorded to prevent scalding. Regular fire drills are carried out and the names of those staff who have participated were recorded to ensure that all staff are captured. The tour of the premises identified some health and safety concerns, which are outlined earlier in this report concerning the storage of items in the unlocked garden sheds and the camber of the garden of bungalow 174. Those staff who have not received Health and Safety training also impacts on safety of service users. Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 2 4 X 5 3 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 2 25 3 26 2 27 2 28 2 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 x 3 X 2 X X 2 x Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 4(1)c Requirement The statement of purpose must be further developed to include the age group of service users, Details regarding staffing levels, how care plans are developed and reviewed and who may be invited to participate and the emergency evacuation process and acknowledgement of the existence of procedures for the evacuation of each service user. Following pre-admission assessment and when the home determines that it is able to meet the needs a letter must be given to the prospective service user confirming this. Service users must be issued with a contract of terms and conditions, which includes details of the room occupied, the fee rate and DS0000066539.V324784.R01.S.doc Timescale for action 31/03/07 2. YA3 14(1)d 28/02/07 3. YA5 5(1)b and 5B(2)a-c 31/03/07 Windward Way Version 5.2 Page 27 individual elements of the fee rate. 4. YA18 12(2) Service users must be given 30/04/07 choices about how they wish to bathe. Service users must be given choices about when they wish to retire. 28/02/07 5. YA18 12(2) 6. YA19 12(1)(a)13(1)(b) All care plans must be signed and dated. Bowel movement charts must be completed and appropriate action taken when lack of bowel function is identified. 13(4)a & 23(2)(a) The layout of the garden in bungalow 174 must be reviewed and measures put in place to prevent accidents to service users. Timescale of 30/10/06 has not been met. Bedroom doors of bungalow 174 must be fitted with suited locks, which can be overridden in an emergency. Assisted bathing facilities must supplied, which meet service users needs. The kitchen units of bungalow 172 must be repaired or replaced. A review of night staff must be carried out, which takes into account service users needs and dependencies and methods for constant observations. Upon completion a copy must be forwarded to CSCI and any DS0000066539.V324784.R01.S.doc 15/02/07 7. YA24 28/02/07 8. YA26 12(4)a 30/04/07 9. YA27 23(2)jn 30/04/07 10. YA28 23(2)b 30/04/07 11. YA32 18(1)a 28/02/07 Windward Way Version 5.2 Page 28 resultant changes actioned. 12. YA35 18(1)(a) Staff must receive training in meeting the needs of older adults. Timescale of 30/10/06 has not been met. 13. YA35 18(1)a The home must complete the already commenced training in Health and Safety for all staff. A system of reviewing the quality of care provided in the home must be developed and implemented. Timescale of 30/10/06 has not been met. 15. YA42 13(4)(c) The build up of unused items in the garden sheds must be removed, kept locked and access by service users must be supervised. 28/02/07 30/04/07 30/04/07 14. YA39 24(1-3) 30/04/07 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 Windward Way DS0000066539.V324784.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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