Inspection on 27/06/06 for Windward Way

This inspection was carried out on 27th June 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 27 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Windward Way 15/01/07

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 Julie Preston Unannounced Inspection 27th June 2006 10:30 Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 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) Care Home 12 Category(ies) of Learning disability (12), Physical disability (12) registration, with number of places Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th November 2005 Brief Description of the Service: 170-174 Windward Way is three adjacent, domestic scale bungalows. Each bungalow has four single bedrooms. The homes are located in the Smiths Wood area of Solihull and provide care and accommodation to twelve people with learning and physical disabilities. Local amenities including Woodland Parks, and shops are within walking distance. Chelmsley Wood shopping centre is about one mile away. Each home has a communal lounge, kitchen/diner, assisted bathroom, separate toilet, and four single bedrooms. 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. Lonsdale (Midlands) Limited are the registered providers. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key fieldwork was conducted over two days and included discussion with staff and service users about the care provided within the home and sampling of the records that describe how needs will be met. A tour of the premises took place and medication systems were looked at. Staff training records were observed as well as health and safety records. The CSCI has had concerns about this home. This fieldwork has identified that although work still needs to be done to make things better a number of big improvements have been made. The registered manager and staff team said they were committed to making these improvements. What the service does well: What has improved since the last inspection? Care plans and risk assessments are more clearly written but further work is needed to make sure they are fully reflective of service users individual needs. The way activities are planned and the opportunities for service users to take part in their chosen ones is much better. There are staff on duty to help service users go out more frequently. Medicine management is better and service users health and well being is protected by this. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 6 Staff have made effort to explain the complaints procedure and the planning of activities to service users in a format they understand. The home is much cleaner and some rooms have been redecorated. Staff have had training to help them meet service users needs and the management of the home is much better. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The home has systems in place to assess the needs of service users prior to them moving into the home. It cannot be satisfactorily demonstrated that the home continues to meet the needs of older service users. EVIDENCE: There have been no new service users admitted to the home since the last inspection. The registered manager confirmed that the policy for admission was being developed by the registered provider, Lonsdale (Midlands) Limited. The service user guide was available for inspection and showed that some effort had been made to present information to service users by use of pictures and symbols. The registered manager went on to explain the process of admission and demonstrated awareness of the need to gather information about prospective service users to ensure their needs could be met within the home. It was noted that two service users are over the age of 65 years, which is not reflected in the homes conditions of registration. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 9 A variation to the conditions of registration is required to be submitted to the CSCI, along with supporting evidence that the home can continue to meet each person’s individual needs. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning and risk assessment has improved but are in need of development to more clearly explain how service users assessed needs are to be met. Service users are supported to make decisions about their lifestyles. EVIDENCE: Care plans and risk assessments were sampled from each house. It was pleasing to note that care plans and risk assessments were more detailed and clearly written than at the previous inspection. Some examples of good practice were noted such as “read and sign” sheets that indicated staff had read and understood care plans and risk assessments. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 11 Further development is needed to make sure that risks identified as part of the care planning process have clear action specified to reduce or control those risks. For example one plan referred to a service user being at risk of choking but did not clarify the action to be taken in the event this occurred. In some cases service users care plans were generic. For example, two service users had the same plan of care in place to manage their epilepsy despite differing needs. Action must be taken to make sure that care plans and risk assessments are reflective of service users individual needs to enable staff to respond accordingly. Service users were observed making choices about where to spend their time and with whom. One service user spoke about choosing a new computer and plasma screen TV for his bedroom. This person said that he had asked for new towels but had not yet received any. On checking with the registered manager it was evident that the towels had been ordered. A member of staff commented that she felt service users were encouraged to make more choices such as when to go out and how to spend their money. This person and other members of staff stated that they felt the management of the home had improved for the benefit of service users. Service users living at Windward Way require support to manage their finances. Records sampled showed that cash balances held on behalf of service users are included as part of the handover process from shift to shift and checked by senior staff for accuracy on a regular basis. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 The quality outcome in this area is good. This judgement has been made using available evidence including a visit to this service. There are opportunities for service users to go out and do things they enjoy. Service users are supported to maintain contact with their friends and relatives. Menus are well balanced and service users enjoy their meals. Record keeping does not always evidence that service users receive a nutritious diet. EVIDENCE: Since the last inspection the manner in which the home is staffed has changed to combine day and residential staff into one team. Several members of the staff team commented that this worked well for service users as activities could continue into the evening rather than the previous practice of activities having to end during the early afternoon when day care staff finished work. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 13 Activity plans were observed which had been developed since the last inspection. Some plans included pictures of activities and a member of staff explained that the plans would be shown to service users to give them information about what had been planned for the day. The staff member also said that service users responses to activities were recorded within their files to build up a picture of what they liked to do and to plan further activities. It was accepted that this is a new process and still being developed by the staff team. Each service user had a copy of their activity plan with a photograph of their Key Worker on their bedroom wall. Sampling of individual daily records showed that service users had been out at least four times a week to attend day centres, college and the local Snoezelam, go for walks and to the shops, garden centre and cinema. During this fieldwork service users went out with family members, to the pub for a meal and shopping for food. It was pleasing to note that service users were supported to maintain contact with their friends and relatives. One service user who had previously attended a local day centre was offered opportunities to meet up with friends from the centre on a regular basis. Written comments were received from relatives praising the staff team for their friendly approach. Staff were observed to knock on bedroom and bathroom doors before entering, which indicated respect to the service user group. It was positive to note that staff included service users in household tasks such as hanging out washing and gardening, which service users appeared to enjoy. Menus were observed which showed that a range of foods were offered including fresh fruit and vegetables. Food supplies were examined and found to be plentiful, however sampling of the records of food consumed by service users evidenced that they had sometimes not been completed which made it difficult to establish that individuals were receiving a balanced diet. These records must be completed to enable this to take place. One service user said he was excited about the opportunity to shop online for food once he had access to the Internet. Service users were observed eating lunch with staff. A choice was offered, as were drinks, both hot and cold. One service user said he liked the food at the home and had particularly enjoyed eating strawberries grown in the garden. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 14 Since the last inspection records of liquid food given to service users who are fed by PEG have been completed in line with guidance issued from the dietician. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 The quality outcome in this 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 their needs and preferences. Service users health care needs are not always well managed which could compromise their well being. Medicine management has improved and in the main service users are protected by robust medication administration practice. EVIDENCE: Service users present during this fieldwork had clearly been supported with their personal care. Staff were observed to discreetly offer personal care to service users throughout this visit. One relative commented, “X is always well cared for by the staff”. Three personal care plans were sampled and each plan was clearly written describing service users preferred routines and the type of support needed to meet their individual needs. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 16 Records were observed which showed that individuals’ responses to personal care had been noted. A member of staff stated that this enabled the team to understand personal preferences such as whether to offer a shower or a bath. Financial records sampled in house number 170 showed that service users buy their own clothes and toiletries. This was further confirmed by service users and staff during discussion. Since the last inspection, health care records have been developed to describe individuals assessed needs and the action to be taken by staff to enable service users to maintain good health. One example of good practice was noted in that “OK Health and Welfare Check” reports had been completed for some service users. The reports specified the person’s health care needs including how the person communicated feeling unwell or being in pain. Action plans were seen for some service users based on the outcome of the Health and Welfare checks and as a result medication reviews and contact with health care professionals had taken place. For other service users this level of detail had not been completed. This must now be implemented to ensure that healthcare is well planned and to reduce the risk of healthcare needs not being identified and met. Moving and handling assessments were seen to be in need of development to clarify how staff are to undertake transfers with service users. For example, one record referred to two staff being required to assist a person to get up, but did not specify what this meant. Staff had completed bowel movement charts for service users at risk of constipation. Some charts showed no entries for up to four consecutive days, which does not enable accurate monitoring to take place. One service user’s records sampled indicated that he had not been offered a dental appointment in 2006. Medication was seen to be securely stored and since the last inspection inner cabinets had been removed as required. In the main, medicine management was satisfactory. PRN (as required) protocols had been agreed with the prescribing GP and included in the record of administration, with one exception. Systems of stock control were in place and medication audits had commenced, records of which were observed. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 17 One potential error was noted where a staff member had entered a code on the medication record to indicate that an 8am dosage of medicine had been given at the service user’s day centre. The registered manager commented that this was unlikely and immediate requirements were made that the matter be investigated. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Relatives are aware of the home’s procedure for raising complaints. Effort has been made by staff to present this information to service users in a format they can understand. Service users welfare is not always promoted by the home’s adult protection procedures. EVIDENCE: Relatives’ comments indicated that they are aware of the home’s procedures for making complaints. There have been no complaints since the last inspection. Effort was seen to have been made by staff to present accessible information about the complaints procedure to service users. One service user said that he would speak to his key worker or any other member of staff if he was not happy with anything at the home and went on to say that he had no complaints at present. Staff files sampled showed that staff members had signed to confirm receipt of the home’s procedure for protecting vulnerable adults and that some had received training in adult protection. An incident was observed where a service user was harmed by another during this visit. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 19 Staff responded appropriately, however immediate requirements were made that security between each bungalow be reviewed as a result to reduce the risk of service users entering other bungalows unnoticed by staff. Staff members demonstrated understanding of the home’s adult protection procedure and talked with confidence about their role in reporting incidents of abuse should this be alleged or suspected. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 30 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The appearance of the premises has improved however some outstanding maintenance issues impact on service users comfort and safety. EVIDENCE: 170-174 Windward Way comprises of three, four bed-roomed bungalows, which are domestic in size and scale. Communal areas and some bedrooms were observed at this visit. Each bungalow was clean and free from unpleasant odour. This is an improvement since the last inspection. Redecoration of bungalow 172 was in progress and the bathroom in bungalow 174 had been fitted with new fire doors and redecorated. A sleep in room no longer in use in bungalow 174 had been converted for use as a staff room, to provide an additional storage area so that staff belongings did not impinge on the space used by service users. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 21 Three bedrooms were observed all of which were clean, well furnished and personalised to service users tastes. A member of staff commented that a service user had chosen new bedroom furniture from a catalogue. One bedroom window was not covered with blinds or curtains and in another bedroom there was no window restrictor in place. These issues must be addressed for the comfort and safety of service users. The bathroom door in bungalow 174 had been fitted with a lock on the inside, which would not enable staff to access the room in the event of an emergency. This must be removed. The floor covering in this room was torn and presented a trip hazard. Again, this must be addressed to reduce the risk of accidents. The lounge carpet in bungalow 174 was stained, worn and is in need of replacement. The home has implemented a policy of disposing of soiled linen when required as at the last inspection it was identified that washing machines did not have a sluice cycle. This had previously been agreed with the CSCI as an appropriate infection control measure. Each bungalow has a laundry room, which as well as housing the washing machine and tumble dryer is used to store COSHH (Control of Substances Hazardous to Health) products. In each room the COSHH cupboard was securely locked to reduce the risk of service users accessing these products. The majority of communal bathrooms and laundry rooms had suitable facilities for hand washing with the exception of the laundry room in bungalow 170, which did not have a supply of liquid soap. The garden to the rear of bungalow 174 remains unsuitable for service users with impaired mobility due to the camber of the lawn and the small amount of patio space available for the three people who use wheelchairs. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. Staff demonstrate knowledge of service users needs and have in the main received training to enable them to do this effectively. Staff recruitment procedures have not always protected service users living in the home. EVIDENCE: Staff were observed to be friendly and respectful to service users throughout this visit. Several staff members commented that the registered manager had made positive changes for the benefit of service users since her appointment in 2005. Staff demonstrated knowledge of service users needs and were able to describe their role in providing support to individuals in a manner consistent with the care plans sampled. This fieldwork has identified that staffing arrangements have changed and examination of the rota showed that more staff are on duty during the evenings and at weekends than were at the last inspection. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 23 The rota also identified a senior member of staff to be on duty during each day shift (8am – 8pm) including weekend shifts. The registered manager and other staff commented that this assisted the shift planning process so that team members knew what they had to do. The staff team were observed to communicate well with each other. For example a staff member consulted another about disabled access to a local pub to ensure that it had suitable facilities for a service user who wished to go there. A service user commented that he thought the staff were “lovely people” and said it “was brilliant” at the home. This was also reflected in the written comments made by relatives and visiting professionals; “I must praise the professionalism and consistency of X (a staff member)” and “thank you for being so pro active with my relative”. Since the new care providers, Lonsdale (Midlands) Ltd took over in November 2005; they have not employed any new staff. The registered manager provided evidence that she had followed up on requirements made at the last inspection to obtain information from the previous providers (Craegmoor Healthcare) to support the recruitment of staff employed by that organisation. With the exception of a photograph of each employee it was noted that CRB (Criminal Records Bureau) checks, references and completed application forms had been received. The inspector was advised that it is Lonsdale’s policy to include service users in staff recruitment and that this would be implemented when vacancies arose. Staff training records were sampled, which showed that a rolling programme of training is implemented by Lonsdale (Midlands) Ltd. Staff had completed mandatory training or dates had been arranged for this to take place later on in the year. One notable exception was training in adult protection, where the majority of staff had not received this. This is required for the ongoing protection of service users living in the home. It was not evident that any staff had received training in meeting the needs of older adults, which in light of the needs of the service user group is needed. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The quality outcome in this area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home has improved creating better outcomes for service users. Some areas of health and safety practice do not protect service users from potential harm. EVIDENCE: The home has a registered manager who is a qualified learning disability nurse and has considerable experience of management and working with people with a learning disability. This fieldwork has identified a number of improvements since the last inspection. The registered manager expressed her commitment to driving further improvements to benefit the service user group. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 25 The registered manager commented that she receives monthly supervision from her line manager. Copies of reports made following visits from a representative of the registered provider were observed. These reports comment on the quality of care provided in the home. It was pleasing to note that action had been taken in response to the reports such as the practice of reviewing service users enjoyment of activities and the implementation of medication audits. Quality assurance systems remain in need of development although it was reported that the home are making an application for Investors in People status in the future. A tour of the premises and observation of records identified some health and safety concerns that must be addressed for the protection of service users. An unmounted fire extinguisher was seen in the hallway of bungalow 174. Garden sheds at the rear of all three bungalows were unlocked and full of items that need to be removed to reduce the risk of harm to service users. Out of date food products were observed in the fridge in bungalow 174. Water temperature records for bungalow 170 showed a range between 46 – 48 degrees Celsius, which could present a scalding risk to service users. There were no individual risk assessments for the evacuation of service users in the event of fire or other emergency. These must be developed based on individuals’ needs. Evidence was seen that the fire alarm system had been tested and serviced on a regular basis as is required. Hoists for transferring service users and assisted bathing equipment had been serviced within the last three months. Accident records were observed which demonstrated that the home have reported these events to the CSCI as is required. It was pleasing to note from training records that staff are due to receive training in health and safety awareness and infection control this year. A food hygiene inspection report was observed (from January 2006) which identified no areas of concern. Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 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 X 2 2 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 2 X 3 X 2 X X 2 X Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation CSA 2000 Requirement Timescale for action 30/09/06 2 YA6 15(1-2) 12(1)(a) A variation application must be submitted to the CSCI for the service users aged over 65 years. Each service user must have a 30/09/06 plan of care that clearly sets out how their assessed needs will be met. Unmet from last inspection. 3 YA9 13(4)(a-c) 4 YA17 17(2) Sch 4(13) 5 YA19 12(1)(a) 13(1)(b) Risk assessments must identify 30/09/06 the controls in place to manage known risks to individual service users. Records of food consumed must 30/09/06 be completed in sufficient detail to enable the reader to determine that the diet offered to service users is nutritious and varied. Accurate care plans must be 30/09/06 developed and implemented to ensure service users health care needs are met. Unmet from last inspection. 6 YA19 13(5) Moving and handling assessments must be reviewed DS0000066539.V293366.R01.S.doc 30/09/06 Windward Way Version 5.1 Page 28 to ensure that clear instruction is recorded about how to support individual service users in this area. Unmet from last inspection. 7 8 YA19 YA19 13(1)(b) 12(1)(a) Service users must be offered regular dental appointments. Bowel movement charts must be completed where this is identified as an ongoing need to enable accurate monitoring to take place. Protocols for the administration of PRN (as required) medicines must be included in the medication administration record. The registered manager must investigate the potential error of the administration of 8am medication in bungalow 174 and report the outcome to the CSCI. The risk assessment for access to bungalows must be reviewed to reduce the risk of service users harming one another. All staff must receive training in adult protection. Bedroom windows must be fitted with restrictors to protect service users security. The internal lock on the bathroom door in bungalow 174 must be removed. The torn floor covering in the bathroom in bungalow 174 must be repaired or replaced. The lounge carpet in bungalow 174 must be replaced. The layout of the garden in bungalow 174 must be reviewed to ensure that the needs of service users accommodated are met. DS0000066539.V293366.R01.S.doc 30/09/06 30/09/06 9 YA20 13(2) 30/06/06 10 YA20 13(2) 30/06/06 11 YA23 13(6) 30/06/06 12 13 14 15 16 17 YA23 YA24 YA24 YA24 YA24 YA24 13(6) 18(1)(a) 13(4)(a, c) 13(4)(c) 13(4)(c) 23(2)(d) 23(2)(a) 15/10/06 27/06/06 30/09/06 30/09/06 30/10/06 30/10/06 Windward Way Version 5.1 Page 29 Unmet from last inspection. 18 19 20 YA26 YA30 YA34 16(2)(c) 13(3) 19 Sch 2 Bedroom windows must be fitted with suitable coverings. Liquid soap must be provided in all bathrooms and laundry rooms. Evidence that robust recruitment practice has been undertaken must be available for all staff working in the home. Unmet from last inspection. 21 22 YA35 YA39 Staff must receive training in meeting the needs of older adults. 24(1-3) A system of reviewing the quality of care provided in the home must be developed and implemented. 13(4)(c) The build up of unused items in the garden sheds must be removed. 23(4)(c)(iv) The fire extinguisher in the hallway of bungalow 174 must be fixed to the wall. 13(4)(c) Systems to ensure that food is used or discarded on or before the best before date must be implemented. Unmet from last inspection. 26 YA42 13(4)(a-c) Hot water must be delivered at temperatures on or close to 43 degrees Celsius to reduce the risk of scalding accidents. 23(4)(c)(iii) Risk assessments must be completed for evacuation of individual service users in the event of fire or other emergency based on their assessed needs. 30/09/06 18(1)(a) 30/10/06 30/10/06 30/09/06 30/09/06 30/09/06 23 24 25 YA42 YA42 YA42 30/09/06 30/06/06 27/06/06 27 YA42 30/09/06 Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 30 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.V293366.R01.S.doc Version 5.1 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: 0845 015 0120 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. Extracts may not be used or reproduced without the express permission of CSCI Windward Way DS0000066539.V293366.R01.S.doc Version 5.1 Page 32 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!