Inspection on 25/09/07 for Windwood Lodge Care Home

This inspection was carried out on 25th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Windwood Lodge Care Home 18/12/06

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 Unannounced Inspection 25th September 2007 10:00 Windwood Lodge Care Home DS0000067585.V352423.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.V352423.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.V352423.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) Forest Lodge 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.V352423.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). 18th December 2006 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). Service users can be admitted for respite or long-term care needs. Care and support planning allows the service users 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. Service users 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 service users 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 service users. 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 service users and their representatives. Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit lasted for about seven hours and took place on 25th September 2007. The manager, the deputy, staff and three of the service users were spoken to. All areas of the house were seen and staff, care and other records were checked. Care staff were asked about the care that service users receive, and were also observed carrying out their duties. Positive feedback was received from a relative, a placement officer and one health professional. This was a key inspection and all of the key inspection standards were tested. What the service does well: What has improved since the last inspection? An appropriate safe guarding adults policy and procedure is in place which reflects local procedures and staff have received appropriate safeguarding adults training. An effective complaints procedure is in place and all service users and their representatives know how and who to complain to. The homes policies and procedures are reviewed and updated as required. Staff are receiving regular supervision so they have a chance to discuss work practice and any concerns. Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 6 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.V352423.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.V352423.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. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of 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 service users’ 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 service users’ basic needs. Service users 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 service users 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 Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 9 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 guide were in each persons bedroom. Therefore appropriate information about the home is available to prospective service users and their relatives. A file for the most recently admitted resident was examined as well as one for a prospective resident. A referral form containing basic details had been completed and an assessment made by the referring social worker. The home also carry out their own assessment of a prospective resident. These assessments cover all of the required areas and include health and culture. A report from the relevant health professionals has also been obtained for the prospective resident. The manager said that the next step would be to arrange for the individual and their relatives to visit the home and trial stays were already taking place with the prospective resident. 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. Although contracts are in place for all service users, for three service users these were not signed. 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. This requirement has been repeated from the last inspection. Windwood Lodge Care Home DS0000067585.V352423.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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of 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. Service users are consulted about their likes and dislikes and are encouraged to make independent decisions as far as possible to enable them to participate in all aspects of life in the home. Appropriate risk assessments must be in place for activities undertaken by the service users in order to promote their independence. Service users’ personal information is safely stored to maintain confidentiality. EVIDENCE: Windwood Lodge Care Home DS0000067585.V352423.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. Three care plans were case tracked and the inspector noted that these contained standard information for each resident. Through discussion the inspector is satisfied that the staff were aware of people’s individual needs and were ensuring that they provided appropriate care to each individual but this is not reflected in individualised care plans. 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 service users 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. The inspector was informed by the manager that they have started to compile pictorial care plans for the service users and this was seen in one of the service users’ rooms. The manager is aware that more needs to be done in this area and that the service needs to involve individuals in the planning of their care which affects their lifestyle and quality of life. A key worker system is in place which allows the staff to work on a one-to-one basis with the service users and contribute to the care plan for the individual. Daily recordings are made about what each person has done and support that they have been given. Basic risk assessments are in place. These identify risks for the service users and staff however these must indicate ways in which the risks can be reduced to enable the service users’ 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. The home ensures that service users are consulted on a regular basis to gather information about their satisfaction levels. Pictorial questionnaires were seen as evidence of appropriate consultation taking place with the service users. Service users’ records and other information is stored in a lockable cabinet in the office and staff are aware of issues of confidentiality. Service users know that their personal information is appropriately kept and their confidences maintained. Individuals understand when staff may have to share personal information. The inspector was informed that one resident requested to see her files which were made available to her. Service users are also aware that Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 12 they can access advocacy services for support and evidence was seen that this has been arranged for one resident who also receives counselling support. Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16,17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users are encouraged to be as independent as possible, to take part in activities and to be part of the local community. Service users are supported to keep in contact with their relatives and friends who are welcomed at the home. Service users are given meals that contain healthy or low-fat options and their dietary needs and individual preferences are always met . EVIDENCE: Service users 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 and taking responsibility for keeping their own rooms tidy. Staff spoken to said that they encourage the service users to do Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 14 as much as possible for themselves. The service users are also encouraged to use public transport to continue to develop their independence. People who use services are involved in meaningful daytime activities of their choice and according to their individual interests and capability. Activity plans were in place for each resident which were drawn up in consultation with them. Some of the service users go to day services for part of the week. On the day of the inspection, two of the service users were accompanied to college by the manager. An art therapist visits the home twice a week to carry out activities with those service users who wish to participate in this. An activities room is available to be used for this purpose. The inspector was informed that the staff work flexible hours to accommodate service users who wish to do different activities. The service users confirmed that they can access and enjoy the opportunities available in the local community by using public transport, library services, the local pub, and leisure facilities such as swimming and going to the cinema. The service users also visited Madame Tussauds, the London eye, London zoo, bowling and went on holiday for a week. They have also gone out on day trips to Southend as well as visiting local fairs. Other activities include visiting a beautician if the female service users choose to do so well as the male are service users may choose to go and play snooker or pool at a local club. One resident goes to an evening club which is organised by Indigo club. Feedback from relatives was that they receive a warm welcome when they visit. All of the service users are encouraged to have regular contact with their families via visits as well as telephone contact. 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. A special diet is in place for two service users who are diabetic. Records are kept of what each person has to eat. Staff are aware that meals provided need to be nutritionally balanced and include healthy options. The service users confirmed that they are involved in menu planning and assisting with the cooking of meals. Two of the service users spoken to stated that they enjoyed the food and that the menu is varied. The meals are wellbalanced and nutritious and cater for the varying cultural and the dietary needs of the individuals using the service. Windwood Lodge Care Home DS0000067585.V352423.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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users receive personal care that meets their individual needs and preferences. The staff team support the service users 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 service users are given prescribed medication safely by staff who have been trained to do so. EVIDENCE: The service users 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 service users were observed to be consulted by staff to make independent choices and decisions with one to one support and discussions. All of the service users go to the local doctor and specialist help is received when needed. Staff take service users to all of their medical appointments. Service users’ files have details of health care issues and show that service Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 16 users have regular access to health care professionals. Records are kept of medical appointments and these show that service users have checks from the optician, dentist and other specialists when needed. Two service users have diabetes that is controlled by diet and tablets. They are supported by regular monitoring at clinics and the staff at the home. However, upon discussion with the staff team it was revealed that not all of them have received diabetes awareness training which could impact on the care provided to service users with specific needs. A requirement has been made in this report to ensure staff receive specific training regarding any conditions suffered by the service users accommodated in the home, to ensure that they are competently able to deliver the care required by service users. The aims and objectives of the home reinforced the importance of treating individuals with respect and dignity. The home has a medication policy, procedures and practice guidance in place. None of the service users are able to self medicate. Only senior staff who have received medication administration training administer medication. The home use the MDS system which is monitored by the boots pharmacist. Medication administration records were checked and the inspector noted that the MAR sheet for one of the service users had been signed for the whole day by the same person when in fact the medication had only been administered once that day. Upon raising this issue with the deputy, the inspector was informed that a member of staff had done this as the previous MAR sheet had been soiled. This is of grave concern as staff must not under any circumstances change or amend the MAR sheets or sign on other peoples behalf. This matter must be urgently dealt with by the management. The inspector also noted that whilst administering medication to one service user, the staff member gave medication to the person and allowed him to walk away with it. He did not actually witness the service user swallowing the medication. Although the service user did take the medication this may not always happen and the staff member can not be certain the service user takes the medication if it is not actually witnessed. A requirement has been made that the medication procedure is always followed by all staff as required. A list of specimen signatures of those staff trained and authorised to administer medication was now in place. Staff have received training regarding the administration of rectal diazepam from the specialist epilepsy nurse. The pharmacist has been holding training sessions with the staff team regarding administration of medication. Medication is securely stored in a locked metal cabinet in the office. Upon examination of the medication cabinet the inspector noted that there was still surplus medication for one of the service users, which the deputy manager agreed must not be kept in the home. This is to be returned to the pharmacy urgently. The policies and procedures for the administration and recording of medication have been reviewed and updated to ensure that the service users are given prescribed medication safely by staff who have been trained to do so, however Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 17 the procedure must be followed by the staff administering medication and close monitoring of this must be carried out by the management team. Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a complaints procedure that would be followed in the event of any complaints being made. Staff have received safeguarding adults training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. This gives service users greater protection from abuse. Service users’ finances are adequately managed and monitored and this lessens the risk of financial abuse. EVIDENCE: Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 19 A complaints procedure is in place which reflects the stages and timescales for action. A pictorial complaints procedure is also in place and is supplied to everyone living at the home. The manager is aware that the complaints procedure must also be displayed in a number of areas within the home. Service users know how and who to complain to. One complaint was recorded from the next-door neighbour, which was satisfactorily resolved. There is a system in place to record all complaints and details of any investigation, action taken and outcome; and this record is checked at least three monthly. The manager has been made aware that all complaints including those made by service users and even minor complaints must also be recorded in a complaints log outlining the details of any actions taken and how they were resolved. This needs to be done so that any trends/ patterns of complaints can be picked up and resolved. The policies and procedures for safeguarding adults are available and give clear, specific guidance to those using them. Staff working at the service know when incidents need external input and who to refer the incident to. One safeguarding adults referral was made which was appropriately handled by the manager following the home’s safeguarding adults policy and procedures. The staff spoken to confirmed that they have received safeguarding adults training and know how to recognise potential abuse and are clear about their responsibilities to report any potential abuse and what the reporting lines should be. Hence, staff spoken to were aware of issues of abuse and all said they had no concerns about the way service users were treated and cared for in the home. Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users 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 March 2005. The house is in keeping with the other properties on the street and a tour of the home showed that it has been furnished 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 Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 21 his or her needs. All of these have an en suite toilet, shower and washbasin. Bedrooms are personalised according to individuals likes. All the service users spoken to said they like their rooms and were comfortable and feel safe in them. There is also a separate bathroom with an assisted bath and a separate toilet and shower and these are suitable to meet the service users’ needs. The shared areas provide a choice of communal space with opportunities to meet relatives and friends in private. There is a large landscaped garden at the back of the house which is enjoyed by the service users during fine weather. There is a separate utility room with laundry facilities where service users can do their laundry independently. All parts of the house and garden were clean and hygienic. Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of 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 service users. There is a procedure for the recruitment of staff, which is robustly implemented to provide safeguards for people living in the home. The home employs staff in sufficient numbers, to meet the needs of the service users. The manager provides good day-to-day support to all staff via regular supervision. The staff team must receive training that is appropriate to meet the specific needs of service users. EVIDENCE: Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 23 Two staff are on duty at all times. The inspector was informed that staffing levels are reviewed and adjusted according to the needs of the service users and the level of support they require. Feedback from staff was that although generally staffing levels are sufficient to meet service users’ needs whilst at home, this needs to be reviewed when the service users go on outings and during peak times. At night there is one member of staff on duty unless it is a male member when two staff are on duty (one female and one male) with on call support from the managers. During the inspection, staff were observed to spend time with the service users, talking to them and giving them the support they needed. They were also observed to deal appropriately and patiently with service users. Staff on duty said that they have received training continually. This has included induction (skills for care induction programme used), safeguarding adults training, manual handling, food hygiene, understanding challenging behaviour, epilepsy, aspergers and autism awareness training. From interviews and discussions held with staff, it was clear that they had a fairly good understanding of the needs of service users but some of the feedback suggested that at times, meeting service users’ needs could be quite a challenge. As the service is registered to provide care to a client group with learning disabilities and associated mental health conditions, the staff must receive appropriate training in order to provide care competently and meet the specific needs of the service users accomodated in the home. It was noted that staff were not provided with all the training that was specific to the needs of the service user group e.g. detailed mental health training and working with people suffering from diabetes. Hence all staff must also undertake specific training as required to meet the service users’ needs. The inspector noted that restraint training has also not been provided and the manager needs to assess this in order to ensure that all staff are competent to deal with any situations where it may be necessary to use restraint. The staff training record showed the courses attended by the staff team and dates of future training. 70 of the staff team have completed NVQ level 2 training with the rest of the team working towards completing NVQ level 2 and one person is working towards achieving NVQ level 3. Three senior staff have completed NVQ level 3. The manager is in the process of devising a further training programme for the coming year in consultation with staff and needs to incorporate the provision of the above training in this programme. There is a wide diversity in the staff team and its composition reflects currently the cultural/gender composition of the people using the service. An advertisement is in place to support one of the service users who is Chinese in order to recruit a suitably qualified person to join the staff team. Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 24 The service has a good recruitment procedure that clearly defines the process to be followed. This procedure is followed in practice with the service recognising the importance of effective recruitment procedures in the delivery of good quality services and for the protection of individuals. The inspector viewed three staff files and these had copies of two written references, and new staff are only confirmed in post following completion of satisfactory police checks and POCA, POVA and the UKCC registers. 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. The registered person is aware that all staff must have regular, recorded supervision meetings at least six times a year with their line manager in addition to regular contact on day to day practice. Staff meetings have been taking place regularly and all of the staff team are involved in these. All staff have statements of terms and conditions and contracts. The manager is aware that service users should be actively supported to be involved in the staff selection process. Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 25 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of 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 service users’ 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 service users. Appropriate management arrangements are in place to ensure that a good quality of service is provided to service users. The health, safety and welfare of the service users are promoted and protected by the systems in place which ensure that overall there is a safe environment for the service users. Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 26 EVIDENCE: 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 deputy manager has completed the NVQ Level 4 and RMA qualification and has also achieved a diploma in community mental health. Both the managers work hard to provide a safe and stimulating environment for the service users. The service users’ 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 service users. Feedback from relatives was that the service is provided in a consistent and caring manner and that the service users are happy because of the good quality of service provided. The manager promotes equal opportunities, has good people skills and understands the importance of person centred care and effective outcomes for people who use the service. The manager ensures that staff follow the policies and procedures of the home, however requirements have been made in order to ensure that staff robustly follow the medication administration procedures and further specific staff training is also required to be arranged as stated under the relevant sections in this report. All records are held securely. Service users would be able to have access to their records upon request. All of the necessary health and safety policies and procedures are in place and the required health & safety checks are routinely carried out to ensure that a safe environment is provided for the service users. The home has a consistent record of meeting relevant health and safety requirements and legislation, and closely monitoring its own practice. Records are generally of a good standard and are routinely completed. The manager ensures risk assessments are completed and taken into account in planning the care and routines of the home. However, although individual risk assessments for each resident are in place as stated previously, they must be reviewed and attached to each care plan as required. 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. 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 Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 27 confirmed a selection of these had been discussed during induction and staff meetings and supervision. Regular fire drills are carried out and the fire drill record sheet includes information about the time of the fire drill and who was present. This information can then be used to check that fire drills are being carried out at different times of the day and night and also that all staff and service users have taken part in fire drills over a period of time. A fire safety procedure is in place. Hot water temperatures are tested each month and also checked each week to ensure that they do not exceed the specified 43°C. A formal quality assurance and monitoring system based on seeking the views of the service users, 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 service users’ family, friends and advocates and all other professionals involved in the care of the service users are also sought about how the home is achieving the goals for the service users. 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 upon request and be filed at the service at all times. Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 28 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 3 23 3 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 2 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 2 3 3 3 3 Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? yes 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. Previous timescale of 31/03/07 not met. Timescale for action 31/12/07 2. YA6 15 31/12/07 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. Previous timescale of 31/03/07 not met. 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. Previous timescale of 31/03/07 not met. DS0000067585.V352423.R01.S.doc 3. YA9 12 31/12/07 Windwood Lodge Care Home Version 5.2 Page 30 4. YA20 13(2) 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. Previous timescale of 31/03/07 not met. 31/12/07 5 YA20 13(2)/18 6 YA35 18 Medication training for staff to be 31/12/07 arranged which is specifically targeted to deal with service users with mental health needs. Training to be provided to the staff group regarding medication interactions and reactions as well as side effects of many of the anti psychotic drugs taken by service users with mental health needs. The registered person must 31/12/07 ensure that all staff attend mental health awareness training in order to equip them to understand and meet the needs of the people they are caring for. Staff must have specific skills and competencies to care for the particular group of people they look after. The registered person must ensure that efficient systems are in place to ensure there is routine monitoring of the service by providing a quality assurance and monitoring process to show the homes of success in achieving the aims, objectives and the Statement of Purpose of the home. 30/12/07 7 YA39 24 Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 31 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 Windwood Lodge Care Home DS0000067585.V352423.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 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.V352423.R01.S.doc Version 5.2 Page 33 - 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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