Inspection on 13/03/08 for Windy Ridge Nursing Home

This inspection was carried out on 13th March 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Windy Ridge Nursing Home 27/09/07

Windy Ridge Nursing Home 13/03/07

Windy Ridge Nursing Home 18/10/05

Windy Ridge Nursing Home 14/06/05

Windy Ridge Nursing Home 22/12/04

Windy Ridge Nursing Home 02/08/04

Windy Ridge Nursing Home 10/02/04

Windy Ridge Nursing Home 25/06/03

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

CARE HOMES FOR OLDER PEOPLE Windy Ridge Nursing Home 32 Barton Lane Barton-on-Sea New Milton Hampshire BH25 7PN Lead Inspector Laurie Stride Unannounced Inspection 13th March 2008 10:10 X10015.doc Version 1.40 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 Windy Ridge Nursing Home DS0000011456.V361879.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 Older People. 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. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windy Ridge Nursing Home Address 32 Barton Lane Barton-on-Sea New Milton Hampshire BH25 7PN 01425 610529 01425 610929 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) MNS Care PLC Position vacant Care Home 21 Category(ies) of Dementia (0) registration, with number of places Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Dementia (DE) The maximum number of service users to be accommodated is 21. Date of last inspection 27th September 2007 Brief Description of the Service: Windy Ridge Nursing Home is a care home offering nursing care and personal care for up to 21 service users that have dementia in the older person category. The home is situated in a quiet residential area of Barton on Sea with access to some local amenities and close to the seafront. Accommodation is provided on two floors with a stair lift that allows access to the first floor. MNS Care PLC owns the service. Fees range from £585 a week for a double room to £680 a week for a single room. This information was obtained at the time of the inspection visit. Members of the public may wish to obtain more up-to-date information from the care home. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was the home’s second unannounced key inspection visit this year, which lasted approximately seven and a half hours, during which we, the commission, looked at how the home was performing in line with the key national minimum standards and also at the progress the service has made in meeting the requirements made at the previous inspection(s). We looked at samples of records and spoke with the new acting manager, who is applying for registration. We also spoke briefly with the administrator and two of the company senior managers and talked more in depth with three members of staff on duty. We met some of the people who use the service, who were not able to communicate verbally with us due to their needs, however we observed staff interacting with people who live in the home in a respectful and friendly manner. Further information used in this report was obtained from the providers’ improvement plan and the previous inspection report. As part of this inspection, responses to survey questionnaires were received from one person’s relative and a staff member and their views are reflected in the main body of the report. What the service does well: The home does well at providing care and support to meet peoples’ individual health and personal care needs. A range of activities are arranged throughout the course of the year to celebrate changes of the seasons and special events in peoples lives such as Summer Fetes, Harvest Festivals, Halloween Parties, birthdays and anniversaries. Visitors are made welcome and the home keeps in touch with the relatives and friends of people who use the service. The home provides wholesome and well-balanced meals and caters for individual preferences. The home offers a bright, clean and comfortable environment in which to live. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 6 A relative who is in regular contact with the service said ‘Windy Ridge is a very good and helpful care home’ and that ‘they are improving the home and care every day’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Improvements have been made to the home’s assessment and admission process to ensure that all the needs of people using the service are met. EVIDENCE: The previous inspection report identified that not all areas of the homes’ assessments of peoples’ needs had been fully completed. This included pre admission details, long-term assessment of needs and life histories for some individuals. Following the previous visit, the service providers had submitted an improvement plan stating that a new assessment form had been developed, which will cover all identified needs and how these needs will be met including referrals to the multi disciplinary team. During this inspection visit, we looked at samples of the homes’ records in relation to four people who use the service, including assessment Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 9 documentation. We saw that the home was using the new assessment tool in relation to a recently admitted individual. The pre-admission information gathered included details of the individuals’ physical and mental health care needs and their ability to carry out day-to-day life skills such as washing, dressing, eating and drinking. Also included were important contact numbers, assessment records from the person’s previous placement, risk assessments, medication, social activities and hobbies. Background information about the person’s life had been recorded with the assistance of their family members, including happy and sad experiences, spiritual beliefs, and favourite/most disliked food/smells/colours. This and other information was being used to develop an individualised plan of care for the person. Full pre-admission assessments had also been carried out in relation to the other individuals whose records we saw, using the older assessment tool. All the assessment records we saw had been reviewed on a regular basis to ensure the information is still relevant. A relative who returned a questionnaire confirmed that they receive enough information about the home to help them make decisions. The home does not provide a service to people requiring intermediate care. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home has made further improvements to ensure the individual health and personal care needs of people who use the service are detailed in care plans and are met by the staff team. People who live in the home are treated with dignity and respect. EVIDENCE: Previous reports had identified the need for care plans to be completed in full and regularly monitored and updated. Requirements were also made in relation to risk assessments and the way that staff members communicate with people who use the service. The service providers’ improvement plan stated that the home manager is to be supernumerary to ensure care plans are completed and reviewed and that staff are supervised. The improvement plan also stated there is a new risk assessment process and that dementia care Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 11 training has been added to the mandatory training programme, to ensure that staff are aware of a person centred approach. We saw that the home has been introducing a new care planning system and records we looked at were well organised, making it easy to see how individuals’ assessed needs are being met. Details of general practitioner and other health care professionals’ visits are documented in each persons’ care records, including information about the outcome and any further action required. All the care plans we viewed had the dates when reviews took place recorded in them. Details of confidential financial or personal matters are held in separate individual files in another locked cabinet, so that access to these is restricted. A staff member who returned a survey questionnaire said they are always given up to date information about the needs of the people they support or care for. Also that they feel they have the right support, experience and knowledge to meet the different needs of people who use the service. Following the previous inspection, the providers’ improvement plan stated that in order to meet the requirement in relation to service users accommodated on the first floor and who are immobile, the service were introducing new risk assessments to cover all activities of daily living for all individuals. People who are immobile and currently residing on the first floor, or their representatives, had been asked if they would like to move rooms but each had chosen to remain in their present room. The homes’ activities co-ordinator is responsible for ensuring that these individuals are provided with social stimulation on a daily basis. We saw evidence that this has been carried out, including updated risk assessments and records showing that social interaction is provided for individuals, in line with their wishes. Prior to our visit we had received information from a member of the public regarding their concern about the services’ ability to deal with the behaviour of one individual who has dementia. We looked at the care records for this person and talked to staff about how they would respond to challenging behaviour. The records showed that the person had been referred to general and mental health professionals, resulting in changes to the individuals care programme. The home had maintained behaviour monitoring records to inform the health professionals in making their decisions. Staff told us that the persons’ wellbeing and behaviour has subsequently improved. Through discussion with three staff members, it was evident that they have a good understanding of Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 12 the reasons why people exhibit challenging behaviour and of how to approach and work with individuals in a positive way. A senior member of staff told us that the home has been working on improving communication with people who have dementia. The homes’ records showed that training in communication, understanding dementia and challenging behaviour has been provided. The new acting manager said that further, more in-depth, dementia training is being organised and this was confirmed by one of the nursing staff. Staff we spoke with demonstrated awareness of the needs of individuals and of issues affecting people with dementia. Through these discussions it was evident that staff recognised the importance of, for example, creating a relaxed atmosphere, recognising and supporting the reality of the individual and working with people in a way that is sensitive to their needs and feelings. A relative who returned a questionnaire indicated that they feel that staff members have the right skills and experience to look after people properly. The relative also commented that the ‘general care is excellent’. Throughout our visit, we observed staff interacting with people who use the service in a respectful, friendly and helpful manner. We saw staff members knocking on doors and waiting for an answer before entering the person’s room, responding to individuals’ queries and concerns and talking to people using their preferred form of address. The home has arranged classes for staff whose first language is not English and the acting manager said a number of staff have already attended. The home has a medication policy and procedure in place. All medications are stored securely including those that should be kept in the fridge and controlled drugs. Since the last inspection all medication records and emergency supplies are stored in one clinical room downstairs. Each bedroom is fitted with a medication cabinet, enabling a more personal approach to the administration of medication. We saw a sample of completed medication administration records, including the register for controlled drugs, which were all signed and up-to-date. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Improvements in the daily running of the home ensure that individual needs for social inclusion and stimulation are met. People who use the service receive appropriate support at mealtimes. EVIDENCE: The previous inspection report required the home to ensure that people who use the service receive their meals in a congenial setting that meets their personal requirements. It also identified a concern about the potential social isolation of people with dementia who live on the upper floor. The service providers’ improvement plan stated that the role of the homes’ activities coordinator role had been reviewed and a more structured daily programme put in place. The allocation of staff at mealtimes had also been reviewed to ensure individuals receive appropriate support. There is a calendar of activities and events on a notice board near the dining area and we saw photographs of events, such as a Valentines’ Day celebration, which had taken place. Another event was planned for Easter and the acting Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 14 manager said that the home holds an event at least once a month, to which peoples’ relatives are also invited. People are also encouraged to try arts and crafts and there is an external facilitator who comes in regularly and encourages people to exercise to music, which people were seen to be enjoying at the time of our visit. The home also employs an internal activities co-ordinator, who works Monday to Friday and who records their interactions with each of the people who live in the home on a daily basis. We saw that this now includes those people living upstairs. Care plans identify those individuals who prefer not to join in with arranged activities, but who still like to spend time talking with someone. The activities co-ordinator was on leave at the time of our visit, but records showed that they spend time chatting with these individuals. A record of interactions is also kept in people’s bedrooms, showing when care staff spend time talking with people as well as supporting them with personal care tasks. Another person’s care plan identifies that they like to wander and short walks are arranged with staff to provide structured opportunities for this to happen outside the home. We observed that this person was supported to access the communal areas from their room on the first floor and return to it as they wished. The previous report also showed that the home welcomes visitors, offering them beverages and an opportunity to have a meal with their relative or friend. Records show that the home continues to do this. A relative confirmed that they are kept up to date with important issues and that the home is meeting the needs of their relative. Two relatives have become volunteers, spending time talking with people in the communal areas. Menus are displayed in communal areas and some people have copies of these in their rooms. Records are kept showing that people are asked about the menu on the day. The acting manager said that if people then change their minds when it comes to the meal, an alternative is offered. We observed the midday mealtime in the conservatory, which provides a comfortable and attractive setting. The meal was served from a hot trolley and we saw that those people who prefer to eat in their rooms are enabled to do so. There were enough staff members on duty on the day to give suitable support to those who require assistance with feeding. This was done at the individuals’ own pace and the atmosphere was relaxed and unhurried. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 15 Special diets are recorded and catered for. Care plans showed that nutritional assessments are undertaken and weight charts are kept and monitored as required. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 People who use the service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home responds appropriately to peoples’ concerns or complaints but these are not fully recorded. People who live in the home are protected from abuse. EVIDENCE: The previous inspection report required the home to provide the people who use the service with an accessible complaints procedure and provide details of other agencies that can be contacted to assist with complaints. The service providers’ improvement plan stated that the complaint procedure and service user guide had been reviewed and the home aimed to produce a version of the procedure in leaflet form. We looked at the homes’ complaints procedure and related records and spoke to staff about how they would assist people to express any concerns about the service. A copy of the complaints procedure was in the hallway and included details of other agencies people can contact, although the details about the Commission for Social Care Inspection needed updating. The procedure is also included in the Service User Guide, a copy of which is kept in peoples’ rooms. There is also Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 17 a version in leaflet form, which also needed some of the contact details updating. The acting manager wrote to us following the inspection informing us that the complaints procedures have been updated. Prior to our visit we had received information from two members of the public regarding individual concerns about the service. As described in the section on health and personal care, we saw how the home had responded to one of these concerns to achieve a positive outcome. With regard to the other concern, the acting manager showed us a letter indicating the home had responded and said that the director of care was dealing with the matter. We discussed with the acting manager the requirement for full details of concerns and complaints to be kept in the home available for inspection. The acting manager wrote to us following the inspection informing us that the service providers audit complaints during regulation 26 visits. A staff member who returned a survey questionnaire said they know what to do if a person living at the home or their representative has concerns about the home. Two of the staff members we spoke with said they would report it immediately to their senior and all three indicated they would know if an individual living in the home had concerns, by observing changes in the persons’ behaviour. A relative who returned a survey questionnaire said they know how to make a complaint and that the home has always responded appropriately if they have raised concerns about the care provided. Throughout our visit we observed a relaxed and friendly atmosphere in the home that is conducive to encouraging people to express themselves. The home has a copy of the local authority safeguarding procedure and a flow chart was displayed in the hall, showing staff what to do if abuse was suspected. Through looking at records and speaking with staff it was evident that training in safeguarding and ‘whistle blowing’ is provided. The staff members we spoke to demonstrated a good understanding of the reporting procedures. The acting manager confirmed there have been no allegations, referrals or investigations. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 21 & 26 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service benefit from the improvements that have been made to make the home more safe, comfortable and suited to individual needs. The home has good infection control procedures in place. EVIDENCE: The previous inspection report identified that people who use the service are provided with a comfortable, clean and homely environment to live in. However a requirement was made that people must have sufficient bathrooms and shower facilities in working order to meet their needs. The service providers’ improvement plan stated that the refurbishment of the downstairs shower room was being planned. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 19 We undertook a tour of the communal areas of the home, kitchen and laundry and also saw the interior of some bedrooms. The home was bright and clean, well ventilated and furnished with good quality furnishings throughout. Bedrooms we saw were clean, tidy and personalised with the occupants’ belongings. There are individualised signs on bedroom doors that have relevance to peoples’ life histories. There is a large enclosed garden accessible to people who live in the home. There is an assisted bath on the first floor. Previous reports have identified that people who are accommodated on the first floor who are immobile are unable to access this facility. As mentioned previously, the homes records showed that individuals accommodated on the first floor had chosen to remain in their present rooms. The refurbishment of the downstairs shower room had been completed and provides access to people with varying abilities. This meets a previous requirement. A further improvement is that the door to this facility is painted in a bright colour and there is a clear sign on it, which helps people to find it. The acting manager told us that since this was done, individuals have been finding their way there independently. The flooring outside the shower room has also been re-fitted to provide a more even surface. The main communal area of the home is a large conservatory, which is fitted with air conditioning units, fans and heaters to maintain a comfortable temperature. New furniture including chairs had been provided since our last visit. There is a fridge nearby so that people can get cold drinks when they wish. A nurse station has been installed close to the main communal area, which enables staff to observe people throughout the day and people who live in the home have quick and easy access to a member of staff. The home has an alarm/call bell system and we observed staff responding promptly when this was activated. Window restrictors and radiator covers are fitted to protect people who use the service. The home has systems in place to minimise the risk of cross infection and we saw staff wearing protective clothing such as disposable aprons and gloves. Staff members receive training in infection control including ancillary staff. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30 People who use the service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Improvements in the training and support given to staff ensure that people who use the service are supported appropriately. Recruitment checks and procedures have also improved to protect people using the service. EVIDENCE: A staff member who returned a survey questionnaire said that there are enough staff to meet the individual needs of all the people who use the service and we saw people receiving appropriate individual support during our visit. The acting manager said that the home plans to recruit an additional staff member for thirty hours a week, commencing in April. Previous reports had identified a requirement for the service to ensure that people using the service are protected by thorough recruitment checks on all new staff prior to commencing employment at the home. The service providers’ improvement plan stated that the recruitment policy and procedure had been reviewed and the home is now using an obtained umbrella organisation for Criminal Records Bureau (CRB) checks. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 21 During our visit we looked at a sample of three staff recruitment records, two of whom had been recruited since the previous inspection. The staff members’ files contained evidence of Protection of Vulnerable Adults (POVA) and CRB checks, two written references and completed application forms. The application form could be further improved to ensure that all applicants provide full employment histories with explanations of any gaps. We discussed this with the office administrator, who said she would take this forward. The administrator said that record keeping in the home has become much more organised under the recent management. As well as the checks on newly recruited staff, we saw evidence that the home has updated the files on all staff to ensure the required information is in place. The previous requirement has been met. A staff member who returned a survey questionnaire confirmed their employer carries out relevant checks before they started work. They also said their induction covered everything they needed to know to do the job when they started ‘very well’. The staff member told us that they are being given training which is relevant to their role, helps them understand and meet the individual needs of people who use the service and keeps them up to date with new ways of working. There is a structured induction for new staff that is based on the Skills for Care Common Induction Standards. The acting manager said that the home has been developing the programme of National Vocational Qualifications (NVQ) for staff, having obtained funding for this. The acting manager said that three care staff already have these qualifications and the homes’ training records showed that six more care staff are working to achieve the awards at level 2 or 3. Staff members we spoke to demonstrated good knowledge of peoples’ needs and how to work with them. All staff spoken to during the visit expressed their motivation and commitment to providing individualised care to people who live in the home. Records seen demonstrated that staff have received mandatory training such as moving and handling, fire training, health and safety, first aid and food hygiene as well as specific training such as dementia care. Training is provided by the acting manager and also by external facilitators. Through speaking with and observing staff it was evident that improvements have been made since the last inspection, in the way that staff communicate and understand the needs of people with dementia. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 37 & 38 People who use the service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. Improvements in management practices ensure safe working practices are maintained, promote the wellbeing and best interests of the people who use the service. Effective quality monitoring and staff supervision will ensure improvement is sustained. Records are generally up-to-date although there are some gaps. EVIDENCE: The home does not currently have a registered manager. The new acting manager, who worked for the company prior to taking on the role, confirmed he is in the process of applying for registration. Through discussion it was evident that the acting manager has enthusiasm for the role, understands the Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 23 importance of person centred care and the continuous development of the service. Staff we spoke to confirmed that the manager is approachable and supportive. The acting manager is supported by the newly appointed director of care, who was visiting the home during our inspection accompanied by the managing director of the company. We saw written reports of monthly monitoring visits by the service providers. We saw the summary report of the home’s quality assurance questionnaire survey conducted in December 2007. The overall results were positive indicating that people felt a good service is being provided. The home holds a ‘relatives surgery’ on the last Friday in the month and also provides a monthly newsletter to people who use the service and their relatives or representatives. The acting manager said the next survey is due later in the month and also showed us a continuous quality-monitoring file he has started to develop. This includes audits of staff inductions, medication and health and safety matters. The acting manager has also been reviewing and updating the homes’ policies and procedures and the organisation of files, which was evident during our visit. The home supports people in managing their personal money and we saw that there is a secure system for this and records are kept of individual accounts and transactions. We saw records of three-monthly staff supervision up until December 2007. The acting manager said he has addressed the need to re-commence formal supervision following management changes in the home. We saw that supervisory allocations had been made and staff we spoke with confirmed they are supervised. The minutes of staff meetings were also seen showing that supervision was being discussed, with a plan of six supervisions per year for each staff member and an annual appraisal. A staff member who returned a survey questionnaire said that their manager regularly meets with them to give them support and discuss how they are working. The staff member also commented that the staff team communicates well and ‘cares well for the service users and provides ongoing support.’ The manager keeps records of the servicing of the homes’ equipment and appliances, such as electrical goods and hoists. We saw the homes’ recent food hygiene reports from the Environmental Health Office, showing that no further action is required, kitchen staff are trained in food hygiene and up-to-date Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 24 guidance is in place. A health and safety inspection report in November 2007 by an external company judged the homes’ environmental risk assessments to be of a suitable standard. We saw the fire safety log book, which was up-todate with details of training, equipment and systems checks. A new fire risk assessment had been carried out since the last inspection, emergency lighting had been installed outside the front porch and a fire door fitted to the linen cupboard to meet fire safety legislation. This meets a previous requirement. As shown throughout this report, a good deal of improvement has been achieved since the last inspection resulting in better outcomes for people who use the service. All of the ten previous requirements had been met and there is evidence of continuing improvement. Complaints documentation is an area where the service could do better. The regular formal supervision of staff is being put in place and we also noted that improvement has been made in communicating to staff the goals and objectives of the service. Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X 2 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 2 3 Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP16 Regulation 17(2) (11) Requirement A record of all complaints and the actions taken by the registered person in respect of any such complaints, must be kept in the home available for inspection. Timescale for action 12/06/08 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 Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Windy Ridge Nursing Home DS0000011456.V361879.R01.S.doc Version 5.2 Page 28 - 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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