Inspection on 18/12/06 for Windwood Lodge Care Home

This inspection was carried out on 18th December 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 no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Windwood Lodge Care Home 25/09/07

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Windwood Lodge Care Home 47 Blake Hall Road Wanstead London E11 2QW Lead Inspector Harina Morzeria Key Unannounced Inspection 12:00 18 December 2006 & 30th January 2007 th Windwood Lodge Care Home DS0000067585.V324593.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 Windwood Lodge Care Home DS0000067585.V324593.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. Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windwood Lodge Care Home Address 47 Blake Hall Road Wanstead London E11 2QW 020 8532 9463 020 8519 5520 liz.handley@btconnect.com 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) Venus Health Care Group Ltd Miss Elizabeth Mary Handley Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (7), of places Physical disability (7) Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To provide care for seven adults (18-65) of either gender with a learning disability (LD) who may also be physically disabled (PD) or have a mental disorder (MD). First inspection Date of last inspection Brief Description of the Service: Windwood Lodge Care home is a residential care home for younger adults with learning disabilities providing personal care and support. It is also registered to provide services to individuals with learning disabilities who may have physical disabilities and/or associated mental disorder (dual diagnosis). Residents can be admitted for respite or long-term care needs. Care and support planning allows the residents and support workers to develop individualised care plans reflecting both short and long-term goals towards achieving effective community integration and social functioning. Individuals are continuously encouraged to take full control of their lives with one-to-one key working and regular reviews of their needs. Residents are enabled to participate in the community by being actively encouraged to join in organised activities in the home, as well as using public leisure facilities and make links with other education, health and social organisations that work with people with learning disabilities. The home is located in a quiet residential area in Wanstead with easy access to local amenities. The home is close to an underground station as well as bus routes. Windwood Lodge is a newly refurbished and specially adapted care home with six rooms and one self-contained flat. The home has been designed to provide a spacious environment which enables the residents to maximise their independence as well as maintaining privacy. All rooms have en suite facilities which are accessible to all disabled users. A lift is also provided giving access to both levels of the house for the residents. The home has been fitted with all modern amenities and is a non-smoking environment. There is a specific quiet/sensory lounge with some sensory equipment, providing a relaxing environment for service users when distressed or displaying raised emotions. There is a large landscaped garden to the back of the house as well as an activities room at the bottom of the garden intended to be used for the provision of day facilities. The fees range from £900 - £2,500 per week. A Statement of Purpose and Service Users Guide are available to the residents and their representatives. Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the first inspection of the service since it registered as a service for younger adults. A second visit was carried out to the home on 30/1/07 in order to check the staff files which were not available at the first inspection. During the visits all of the key standards were checked. The manager, staff and three of the residents were spoken to. All of the communal rooms in the house were seen as well as two bedrooms and the self contained flat. Care and other records were checked. Four relatives and other professionals were asked for their opinion of the service by telephone. What the service does well: What has improved since the last inspection? Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 6 This is the first inspection of the service and therefore it is not possible to assess improvements. 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. The summary of this inspection report can be made available in other formats on request. Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 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 Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is obtained to enable the staff team to decide whether or not the home can meet the prospective residents’ needs. The required information would be gathered on a prospective resident and they and their relatives could spend time in the home to find out what it would be like to live there. Information is available to enable the staff team to meet residents’ basic needs. Residents have individual contracts or a statement of terms and conditions with the home, so that they are clearly aware of the services that the home can offer. However the contracts must be signed by all parties involved. EVIDENCE: The Statement of Purpose and the Service User Guide were examined. These contain up to date information about the service provided in the home so that prospective residents have the information they need to make an informed choice about where to live and whether their needs will be met by the home they enter. The Service User Guide is in a pictorial format and contains lots of photographs of the home and the people that live there. The complaints procedure in a pictorial format is also included. Copies of the service user Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 9 guide were in each persons bedroom. Therefore appropriate information about the home is available to prospective service users and their relatives. Two files for the most recently admitted residents were examined. A referral form containing basic details had been completed and an assessment made by the referring social worker. These assessments cover all of required areas and include health and culture. The manager said that the next step would be to arrange for the individual and their relatives to visit the home. If it were agreed that this person would like to live at the home then a transition plan would be developed. Therefore sufficient basic information would be gathered on a prospective resident to enable the staff team to identify their needs. A requirement has been made elsewhere in this report regarding the development of detailed person centred plans so that residents’ individual needs can be identified and met by the staff. Although contracts and/or a statement of terms and conditions with the home were on file, not all of them were signed by all the parties involved with the individual’s care. The registered person is required to ensure that there is a signed contract / statement of terms and conditions in place between the home and the resident/representatives. Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Basic care plans for each resident are in place so that staff can meet their needs. However these need to be individualised for each resident. Residents are consulted about their likes and dislikes and are encouraged to make independent decisions as far as possible. Appropriate risk assessments must be in place for activities undertaken by the residents in order to promote their independence. Residents’ personal information is safely stored to maintain confidentiality. EVIDENCE: Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 11 Each resident has a basic care plan which outlines their needs and how these will be met. Four care plans were case tracked and the inspector noted that these contained standard information for each resident. Although there was evidence that for one resident the staff were aware of his individual needs due to food allergies and were ensuring that he was provided with an appropriate diet. However this was not outlined in his care plan. Staff were also aware of another residents’ medical condition and appropriate strategies were in place. The registered person must ensure that the care plans are individualised and person centred, based on each person’s specific needs, outlining how these will be met by staff. The plans must give details of how each person likes and needs to be supported. There was little evidence to show how the residents have been involved in the development of the care plans. The care plans must clearly describe a person’s behaviours, why they exhibit these behaviours and what to do. This will ensure that all staff have correct and full information about individuals. Daily recordings are made about what each person has done and support that they have been given. However the daily records must detail how care plans are being met in order to give a clear picture of how a residents’ needs are being met. This will also ensure that there is detailed information about each resident, which can be used as part of the review process and to identify ongoing and changing needs. Basic risk assessments are in place. These identify risks for the residents and staff however these must indicate ways in which the risks can be reduced to enable the residents’ needs to be met as safely as possible. The registered person must ensure that once individualised care plans have been developed for each resident then the risk assessments are attached to each care plan /activity involving a risk to the resident, giving clear information to staff about what actions must be taken to reduce the risk. The care plans and risk assessments must be regularly reviewed and updated. Residents’ records and other information is stored in a lockable cabinet in the office and staff are aware of issues of confidentiality. Residents know that their personal information is appropriately kept and their confidences maintained. Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are encouraged to be as independent as possible, to take part in activities and to be part of the local community. Residents are supported to keep in contact with their relatives and friends who are welcomed at the home. Residents are given meals that contain healthy or low-fat options and their dietary needs and individual preferences are always met . EVIDENCE: Residents are encouraged to develop their skills and each person contributes to the tasks in the home as far as they are able. This may be to help clear the table, wash up or clean their own rooms. Staff spoken to said that they encourage the residents to do as much as possible for themselves. Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 13 Not all of the residents have access to day services as the home has recently been registered and the staff are in the process of registering residents at various establishments/colleges according to their preferences. Most of the residents are independent, only sometimes needing support from the staff team when they go out. They visit local pubs, leisure facilities, shops and cinemas. Residents are asked where they want to go and what they want to do. At the start of the inspection one resident was at home and was waiting to go out with a member of staff and another resident had been out independently. One other resident spent most of the day in his room preferring to watch day time television. The staff said they do encourage him to participate in some of the activities taking place in the home but he makes his own choices. Staff also said that some of the residents enjoy going to the library, shopping and swimming. Some residents also enjoy watching DVD’s and one of the residents enjoys listening to music which staff facilitate. Residents are given opportunities for social activities and are supported when they wish to do those activities. The staff team should start to develop an activities plan with each resident about what they would like to achieve so that there is a planned programme in place to achieve their goals. The inspector was informed that staff hope to offer art and music therapy. An activities room is available to be used for this purpose but the facility is not in use yet. Feedback from relatives was that they receive a warm welcome when they visit. All of the residents are encouraged to have regular contact with their families via visits as well as telephone contact. The staff team were supporting one of the residents to attend his friend’s funeral the day after the inspection. Discussions were also held with the manager that an activities programme should also be developed for the two residents who stay for respite care on a regular basis. Feedback received also indicated that the residents have little to do in the evenings and weekends apart from watching television or DVDs at home. This is not sufficient particularly as the average age range of the residents accomodated is mid to early 30’s. Hence, the inspector recommends that the registered person holds a meeting with the residents to discuss which activities they wish to do in the evenings/ weekends and organise a planned programme of leisure activities according to this. There is a varied menu that is developed by staff and it is based on the knowledge of the residents’ likes and dislikes. A large fully fitted kitchen is available to prepare meals. Another specially adapted hob/cooker and an accessible sink is also in place to enable wheelchair users to prepare food independently. All staff have completed food hygiene training and certificates were seen on file. There is a separate cabinet containing specific food items for one of the residents who has a food allergy and epilepsy. A special diet is in place for another resident who is diabetic. He confirmed that his specific dietary needs are catered for in the home and staff were observed to discuss his food choices when preparing the evening meal. Records are kept of what Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 14 each person has to eat. Staff are aware that meals provided need to be nutritionally balanced and include healthy options. Windwood Lodge Care Home DS0000067585.V324593.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): 18,19,20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal care that meets their individual needs and preferences. The staff team support the residents to get the health care that they need. The policies and procedures for the administration and recording of medication must be reviewed and updated to ensure that the residents are given prescribed medication safely by staff who have been trained to do so. EVIDENCE: The residents require support with their personal care in varying degrees and basic details of the help that they need and how they prefer to be supported are in their individual plans. On the day of the inspection residents were observed to be constantly consulted by staff to make independent choices and decisions with one to one support and discussions. All of the residents go to the local doctor and specialist help is received when needed. Staff take residents to all of their medical appointments. Residents’ files have details of health care issues and show that residents have regular Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 16 access to health care professionals. Records are kept of medical appointments and these show that residents have checks from the optician, dentist and other specialists when needed. One resident has diabetes that is controlled by diet and insulin. He is supported by the district nurse and the staff at the home. Records show that the staff monitor him regularly and take the necessary action if any problems arise, for example, to give him something to eat or drink and then check again. His diabetes is well managed and controlled by the staff team who have received diabetes awareness training. None of the residents are able to self medicate. Only senior staff who have received medication administration training from Boots, administer medication. The home use the MDS system which is monitored by the boots pharmacist. Medication administration records were checked and found to be properly completed. However a list and specimen signatures of those staff trained and authorised to administer medication was not in place. A training session was planned for staff to receive training regarding the administration of rectal diazepam from the specialist epilepsy nurse. The pharmacist has been doing training sessions with the staff team on the administration of medication. Medication is securely stored in a locked metal cabinet in the office and is appropriately administered by the staff team. Upon examination of the medication cabinet the inspector noted that there was a lot of surplus medication for one of the residents, which the manager agreed must not be kept in the home. This is to be returned to the pharmacy urgently. The medication policy and procedure was also examined. It did not accurately reflect the procedures followed by the staff in the home and therefore must be amended. Medication must be safely administered following the home’s procedure to ensure that residents receive the correct medication and to minimise the risk of an error. The policies and procedures for the administration and recording of medication must be reviewed and updated to ensure that the residents are given prescribed medication safely by staff who have been trained to do so. Windwood Lodge Care Home DS0000067585.V324593.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): 22,23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A clear complaints procedure with timescales must be developed so that residents and their representatives know that their vies are listened to and acted on. Staff were aware of issues about adult protection and the need to protect residents from abuse. However, robust procedures for responding to adult protection issues must be in place so that residents are protected from abuse, neglect and self harm. EVIDENCE: The current complaints procedure does not reflect the stages and timescales for action. Hence the manager is required to ensure that it is updated to include the stages of and timescales for the process, and that residents know how and who to complain to. It must also be available in a user-friendly format . Two complaints were recorded. One was from the next-door neighbour, which was eventually resolved after intervention from the CSCI. The registered person must ensure that there is a system in place to record all complaints and details of any investigation, action taken and outcome; and this record must be checked at least three monthly. The staff group have completed basic adult protection training during induction. They are waiting to attend the London Borough of Redbridge Adult Protection training course. Upon examination of the home’s adult protection policy and procedure, the inspector noted that it does not accurately reflect the local procedures. The registered person must ensure that an accurate and Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 18 appropriate adult protection policy and procedure is in place (including whistle blowing) which reflects the London Borough of Redbridge procedures for the protection of vulnerable adults. It must also be developed in accordance with the Public Interest Disclosure At 1998 and Department of Health guidance No Secrets. The staff team must be equipped/trained to recognise potential abuse and they must be clear about their responsibilities to report any potential abuse and what the reporting lines should be. Staff spoken to were aware of issues of abuse and all said they had no concerns about the way residents were treated and cared for in the home. Windwood Lodge Care Home DS0000067585.V324593.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): 24,25,26,27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a purpose built home that is suitable for their needs. Bedrooms and communal areas are spacious, meet their needs and promote their independence. Toilets and bathrooms provide sufficient privacy. Shared spaces are spacious and sufficient space is available for the numbers of people living in the home. The home is clean and hygienic. EVIDENCE: The home is purpose built, and was opened in May 2006. The house is in keeping with the other properties on the street and a tour of the home showed that it has been refurbished and specially adapted to meet the needs of people with special needs. A lift has also been installed to make all areas accessible to people in wheelchairs. Each resident has a single bedroom that is suitable for his or her needs. All the residents spoken to said they like their rooms and Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 20 were comfortable and safe in them. All of these have an en suite toilet, shower and washbasin. Bedrooms are personalised according to individuals likes. There is a separate bathroom, with an assisted bath, and a separate toilet and shower and these are suitable to meet the residents’ needs. There is a large landscaped garden at the back of the house which is enjoyed by the residents during fine weather. There is a separate utility room with laundry facilities where residents can do their laundry independently. All parts of the house and garden were clean and hygienic. One relative stated that “the place is spotless and always clean and her relative is always clean”. Windwood Lodge Care Home DS0000067585.V324593.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): 31,32,33,34,35,36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All staff have job descriptions which outline their roles and responsibilities, ensuring that they understand the tasks required of them in order to promote and protect the well being of residents. There is a procedure for the recruitment of staff, however this must be robustly implemented to provide safeguards for people living in the home. The home employs staff in sufficient numbers, to meet the needs of the residents. The manager provides good day-to-day support to all staff via regular supervision. Staff are receiving the necessary training to give them the skills to meet the residents’ current needs and provide an appropriate service to them. EVIDENCE: Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 22 Two staff are on duty at all times. Feedback from staff was that this was sufficient to meet residents’ needs. At night there are two members of staff on duty, with on call support from the managers in the event of an emergency. Staff were clear about their duties and responsibilities towards the residents. The inspector was informed that staffing levels are reviewed and adjusted according to the needs of the residents and the level of support they require. During the inspection, staff were observed to spend time with the residents, talking to them, and giving them the support that they needed. They were also observed to deal appropriately and patiently with residents who were exhibiting some challenging behaviour. Staff on duty said that they had received training since they started work in the home. This has included induction (skills for care induction programme used), adult protection awareness, manual handling, food hygiene, understanding challenging behaviour, diabetes awareness training, as well as other specialist training as required to meet the residents’ needs. The staff training record showed the courses attended by the staff team and dates of future training. Two staff are working towards completing NVQ level 2 and one is working towards achieving NVQ level 3. Three senior staff have completed NVQ level 3. Therefore, the staff team are receiving ongoing training to enable them to meet residents’ needs. The manager is in the process of devising a further training programme for the coming year in consultation with staff. One relative spoken to felt that although the care delivered in the home was good, the staff were not able to communicate effectively with her daughter, as they were not able to communicate in makaton with her. The manager did recognise this during the inspection and is arranging for staff to attend this training. The staff team currently in place is reflective of the cultural/gender composition of the residents. The inspector was not able to examine the staff files during the first visit as they were stored at the head office, but was able to do so on 30/1/07 when a second visit to the home was made to examine staff records. The company generally operates an appropriate recruitment procedure that protects and safeguards residents. Jobs are advertised, application forms completed and interviews held. The necessary checks are undertaken prior to staff commencing employment. Two written references are obtained and new staff are only confirmed in post following completion of a satisfactory police check, and the POCA, POVA and UKCC registers. Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 23 Staff are employed in accordance with the codes of conduct and practice set by the GSCC. All staff have statements of terms and conditions and contracts. The manager is aware that residents should be actively supported to be involved in the staff selection process. However, during the inspection process the inspector was made aware of false information/documents given by one member of staff. This issue is being dealt with by the manager and the inspector will be informed of the outcome upon completion of the investigation. A requirement has been made that although the recruitment process has been generally followed, this must be thoroughly implemented in a consistent manner to avoid future such concerns arising. All staff files must be organised in a way that enables easy access to information i.e. appropriate sectioning of files. Each staff file must contain a photograph of the member of staff, for ease of identification. Staff meetings have been taking place regularly and all of the staff team are involved in these. Staff spoken to confirmed that they had been receiving supervision and evidence of this was seen when checking staff files. This ensures that staff have an opportunity individually and collectively to discuss issues, concerns and the development of the service. Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42,43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is an experienced and qualified person. The home is run in a way which ensures that the residents’ best interests are safeguarded by the home’s record-keeping. Staff are aware of the lines of accountability and monitoring systems within the home are robust enough to ensure that the manager is fully appraised of any issues relating to the day-to-day running of the home and the specialist needs of the residents. Appropriate management arrangements are in place to ensure that a good quality of service is provided to residents. The health, safety and welfare of the residents are promoted and protected by the systems in place which ensure that overall there is a safe environment for the residents. EVIDENCE: Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 25 The manager is experienced and has managed the home sine the home was registered. She is a registered RMN and is in the process of completing the Registered Managers Award. The home is run in a way which provides a safe environment. The deputy manager has also completed her NVQ Level 4 and RMA qualification. Currently she is working towards achieving her mental health diploma. Both the managers work hard to provide a safe and stimulating environment for the residents. The residents’ health, safety and welfare are met by the staff working in the home. However, comments and requirements have been made elsewhere in this report to further improve the standards of care for the residents. Feedback from relatives was that the service is provided in a consistent and caring manner and that the residents are happy because of the good quality of service provided. All records are held securely. Residents would be able to have access to their records upon request. All accidents are recorded and appropriate action is taken when required. Induction training for new staff is being achieved with further ongoing training being offered. Individual risk assessments for each resident are in place but as stated previously they must be reviewed and attached to each care plan as required. All of the necessary health and safety policies and procedures are in place and the required health & safety checks were carried out prior to the registration of the service in March 2006 to ensure that a safe environment is provided for the residents. However the policies and procedures were compiled by a consultancy consortium and are therefore basic. Upon discussion with the manager she agreed that these policies and procedures need to be reviewed and be more specific to the home and the service being provided. The company’s policies and procedures were readily accessible in the office and some of these were discussed with the staff team. Staff spoken to were aware of where policies and procedures and other information was stored and confirmed a selection of these had been discussed during induction and staff meetings and supervision. All necessary health and safety checks were carried out prior to registration of the service and a safe environment is provided for the residents. A food safety inspection was carried out before the home was registered and stated that there were good standards in the home with regards to food safety. One fire drill was held since registration. The fire drill record sheet includes information about the time of the fire drill and who was present. This information is used to check that fire drills are being carried out at different times of the day and night and also that all staff and residents have taken part in fire drills over a period of time. Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 26 There is a fire procedure which does not cover the action that should be taken in the event of a fire during the night. A fire procedure must be developed to ensure to all staff are aware of the correct action to be taken in the event of a fire at night when all the residents are in bed and less staff are on duty. Hot water temperatures are tested each month but must be checked each week to ensure that they do not exceed the specified 43°C. Advise was given to the manager to ensure that a health and safety check of all areas is carried out each week which should be logged to ensure that a safe environment is maintained at all times. A formal quality assurance and monitoring system based on seeking the views of the residents, to measure success in achieving the aims and objectives of the home is in place. The registered person has begun the consultation process and is aware that the views of the residents’ family, friends and advocates and all other professionals involved in the care of the residents are also sought about how the home is achieving the goals for the residents. This information will then be available in an annual report. The responsible individual undertakes monthly monitoring visits to the home in compliance with the Regulation 26 of the Care Home’s Regulations 2001, to monitor and report on the quality of the service provided in the home. These reports are made available to the Commission promptly. Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 2 3 3 3 Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 28 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation 5 Requirement The registered person to ensure that each individual contract or statement of terms and conditions with the home is signed by all parties involved in the care of that individual. The registered person must ensure that each resident has an individual care plan which reflects his/her personal goals and how these will be met by the home in consultation with the resident and his/her representatives. The registered person must ensure that appropriate risk assessments are in place and these must be attached to that individual’s care plan so that all staff are aware of how to deal with any situation that may arise. The registered person must ensure that suitable arrangements are in place for the recording, handling, safekeeping, safe administering and disposal of medicines received into the care home. The registered person must DS0000067585.V324593.R01.S.doc Timescale for action 31/03/07 2 YA6 15 31/03/07 3 YA9 12 31/03/07 4 YA20 13(2) 31/03/07 5 YA23 13(6) 31/03/07 Page 29 Windwood Lodge Care Home Version 5.2 6 YA22 13 ensure that there is a suitable adult protection policy and procedure in place which reflects local procedures. Staff must also receive appropriate training in adult protection in order to ensure they are aware of proper procedure to be followed if an incident is reported. The registered manager to 31/03/07 ensure that there is a clear and effective complaints procedure which includes the stages of, and timescales, for the process, and that residents and their representatives know how and who to complain to. The registered person must 31/03/07 ensure that the home’s policies and procedures are reviewed and are individual to the home. 7 YA40 17 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 YA14 Good Practice Recommendations The inspector recommends that the registered person holds a meeting with the residents to discuss which activities they wish to do in the evenings/ weekends and organise a planned programme according to this. Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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. Extracts may not be used or reproduced without the express permission of CSCI Windwood Lodge Care Home DS0000067585.V324593.R01.S.doc Version 5.2 Page 31 - 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. 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