Inspection on 02/03/04 for Winnett Cottage

Care Homes For Adults (18 ­ 65)Winnett Cottage111 Hertford Road Bragbury End Stevenage Hertfordshire SG2 8SHUnannounced Inspection3rd March 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Winnett Cottage Address 111 Hertford Road, Bragbury End, Stevenage, Hertfordshire, SG2 8SH Email Address winnett@psycare.co.uk Name of registered provider(s)/Company (if applicable) Psycare Hostels Name of registered manager (if applicable) Mr Russell Fletcher Type of registration Care Home (PC ­ Personal Care) No. of places registered (if applicable) 10 Tel No: 01442 878504 Fax No: 01442 861152Categories of registration, with (number of places) Mental disorder, excluding learning disability or dementia : 10 Registration number I020000326 Date First registered 6th December 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 6th December 2002 NO NO 11/9/03 If Yes Refer to Part CWinnett CottagePage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 33rd March 2004 09:30 am Mr Ali Soobhany None None NoneID Code076675Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at the time of inspectionNone None Mr F Fletcher, managerWinnett CottagePage 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where applicable) Providers Response Providers comments Action Plan Providers agreementWinnett CottagePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the NCSC in respect of Winnett Cottage. The inspection findings relate to the National Minimum Standards (NMS) for Care Home published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000 and the Children Act 1989 as amended. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Winnett CottagePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Winnett Cottage is a psychiatric aftercare hostel accommodating a maximum of ten adults in individual rooms. There are various communal areas including a large day room, a TV room and a communal dining room. The garage has been converted to provide an on-site leisure facility with a gymnasium and a recreation area. Visiting professionals may use a quiet interview room. The hostel is located in a quiet residential area on the outskirts of Stevenage and close to a local parade of shops. Stevenage Town Centre with its range of commercial outlets, amenities and public service links to other towns is easily accessible. Service users are allocated an individual care pathway facilitator who will encourage and support the service user in formulating and implementing their own daily living programme and lifestyle plan.Winnett CottagePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This is the second inspection of this home since it was registered. Present at this inspection were the manager, 2 members of staff and 6 service users, 2 service users having already left for work. Services users spoken with were full of praises for the staff and for the care, services that they are receiving. Choice of Home (Standards 1-5) None of these standards were assessed on this occasion. Individual Needs and Choices (Standards 6-10) Only 4 standards were assessed on this occasion and these were met. The home has not had any new admission to the home since its last inspection. Services users were very vocal about the good quality of care in the home and highly praised staff. Care plans and risks assessment and management plans are in place. CPA meetings are held regularly and the home staff work very closely with staff of the respective Care Teams who have placed the service users in the home. Lifestyle (Standards 11-17) Only 4 standards were assessed on this occasion and these were met. Service users are able to act and think independently and are actively encouraged to exercise independence and choice and to be engaged in whatever activities they choose to do. Personal and Healthcare Support (Standards 18-21) Only 2 standards were assessed on this occasion. One was met. Service users physical and mental health are well monitored by staff. All service users are regularly seen by their respective psychiatric services. One standard was not met. There were several gaps in the records of administration of medicines to service users. As a result, an immediate requirement has been made. Concerns, Complaints and Protection (Standards 22 & 23) Only 1 standard was assessed on this occasion and this was met. The home has a comprehensive complaint procedure, which has been distributed to all service users who know how to use it. Environment (Standards 24-30) None of these standards were assessed on this occasion Staffing (Standards 31-36) Only 5 standards were assessed on this occasion and these were met. The home deploys adequate staff on duty daily and staff members have received appropriate training and individual supervision. The home recruitment procedure meets standards and regulations. Staff members spoken with were very enthusiastic about their work, appeared committed and were knowledgeable of service users care needs. Conduct and Management of the Home (Standards 37-43) Only 3 standards were assessed on this occasion. Two standards were met. The manager was recently registered with the NCSC and operates an open door policy, which staff confirmed and they feel well supported. One standard was not met, as the registered provider is not producing a report of their monthly visits to the home. As a result, a requirement has been made. Winnett Cottage Page 6 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action Two of the three requirements made at the last inspection have been met. YA38 Psycare Hostels must arrange for monthly visits to the home in accordance with this regulation and for the report generated from 24/10/03 that visit to be available to the manager and the Commission. This requirement has not been fully met and has therefore been brought forward Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard Three out of the 5 recommendations made at the last inspection have been implemented. The manager is currently working on the other two recommendations made and hope to have these implemented by the time of the next inspection CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS). There are no additional conditions of registration.226MET (YES/NO)Winnett CottagePage 7 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 13(2) YA20 Accurate records of medicines administered 03/03/04 to service users must be kept The person carrying out the monthly visit of the home on behalf of the registered provider must prepare a written report of the conduct 22/03/04 of the home and supply a copy to the NCSC and a copy to the registered manager226(4) (c) & 26 (5) (a) & (b)YA38RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * None · Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Winnett CottagePage 8 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES NA YES YES NO NO NO YES YES YES YES YES YES NA NA NA NO NO YES 6 X X NO YES YES YES X X 02/03/04 9.30 3Winnett CottagePage 9 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Winnett CottagePage 10 PLEASE NOTE THAT TEXTS FROM PREVIOUS INSPECTION REPORTS HAVE BEEN INCORPORATED IN THIS REPORT WHERE THERE HAVE BEEN NO MAJOR OR SIGNIFICANT CHANGES FROM PAST INSPECTIONSChoice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives, philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. 850.00 950.00 Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are Key findings/Evidence This standard was not assessed on this occasion.Standard met?0Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user using an appropriate communication method, and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Winnett CottagePage 11 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis, before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Winnett CottagePage 12 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? Each service user has a primary and secondary Care Pathway Facilitator (member of staff) assigned to them to ensure that there are appropriate care plans in place and that these are reviewed as and when needed. The manager is in the process of re organising this system to make it more effective. Currently each service user has two care files, one originated by; the individual Care Team and a needs orientated multi-disciplinary information system (NOMIS) originated in the hostel. The manager intends to review the latter so that service users short and long-term goals are better elicited and that care plans become more of a daily working tool. Service users confirmed that they are fully engaged with staff in the care planning process and they were clear about the respective roles and responsibilities of all the professionals they come into contact with at the hostel. Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions and that right is limited only through the assessment process, involving the service user and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? `Empowerment is the cornerstone of the whole therapeutic practice at this hostel. Service users have control of their own Benefits. Staff have a range of processes through which they can support service users, (e.g. through one-to-one sessions and community meetings). Individual choices are included in Care Team care plans, CPA, and would show up through the NOMIS system. Any limitations on use of facilities, choices etc. are discussed through multi-agency CPA as well as through one-to-one sessions and Care Team care plans, (all of which processes involve the individual service user).Winnett CottagePage 13 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day-to-day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? There are two community meetings held each week, one of which is a menu planning meeting. All service users have been given written details of polices, procedures, activities etc. and these are discussed at the community meetings. The manager is currently developing a service user satisfaction questionnaires, which will form part of the quality assurance process.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Identified risks are minimised and the homes risk assessment approach is regularly reviewed via the Care Teams, through discussion and at care plan approach meetings. There is an `Absent Without Leave process that would involve local police and identified Care Team staff after a pre-determined lapse of time.Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998 and in the best interests of the service user. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Winnett CottagePage 14 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Service users are encouraged to exercise their practical life skills through use of local public facilities as well as having opportunities to join in with life skills within the hostel. The hostel does not offer treatment and recovery programmes per se, although staff assist in treatment and recovery programmes where they form part of service users Care Team care plans. Any spiritual needs are identified during the assessment process and assistance would be offered as appropriate.Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities 3 Key findings/Evidence Standard met? Staff offer assistance to service users in determining what they would like to do in terms of on-going education or employment. Two service users hold regular paid jobs. One of them also works as a volunteer in a charity shop. Three service users are currently redecorating the lounge and they are being paid by the organisation for doing so. All three also attend collegial activities. One service user is in touch with Employment Direct with a view of securing a gardening job. Two service users prefer not to be engaged in any paid or unpaid jobs.Winnett CottagePage 15 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in the local community in accordance with assessed needs and the individual Plans. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to and choose from a range of appropriate leisure activities. 3 Key findings/Evidence Standard met? The home is ideally located to enable service users to access the range of activities available in the new town and staff support and encourage involvement. The home also has access to a mini bus and this enables small outings to be arranged for individuals who share a common interest. Service users have not yet showed a wish for larger group outings. Within the home, SKY television has been installedStandard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Winnett CottagePage 16 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Apart from pre-agreed appointments, service users are actively encouraged to exercise independence and choice. Unless there is an obvious emergency, staff will knock and wait to be invited to enter service users bedrooms. All service users have been given the key to their own bedroom door lock. Staff do not intercept service users mail. Service users prepare some meals for themselves and those service users who cook for others have completed a food hygiene and kitchen induction programme. There are rotas for cleaning and washing up although the former task is undertaken with the housekeeper. Service users preferred mode of address is recorded when needed. The home has a `No pet policy. Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Winnett CottagePage 17 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes policies and procedure for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No of service users with pressure sores at the time of inspection (from information taken from care notes) 003 Key findings/Evidence Standard met? All service users have external care teams and all planning is done collaboratively. GPs are allocated via the local Health Authority. GPs encourage service users to have general check-ups and offer appropriate advice. Any visits by GPs to service users at the hostel take place in private. The hostel also reviews healthcare needs and seek specialist advice where needed. All service users are under CPA arrangement. They have regular reviews by their respective psychiatric services and there are good communication channels between the home staff and the psychiatric services. CPNs and Social Workers also visit service users on a regular basis.Winnett CottagePage 18 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 1 Key findings/Evidence Standard met? Two service users have their medicines dispensed in the NOMAD blister pack and these are administered by staff members. There were several gaps noted in the records of administration of medicines of these 2 service users. The other service users administer their own medication and staff carries out discrete monitoring to ensure compliance. These service users signed for receipt of their own medicines and they are each supplied with a key to their bedroom. Stock medicines are stored in a `Bristol Maid cabinet in the office. There were no controlled drugs prescribed to any service users at the time of this inspection. All staff members have received `Care of Medicines training. Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? Standard not assessed on this occasionWinnett CottagePage 19 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure which includes the stages of and times-scales for the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days 0 X X X X X X 3 Key findings/Evidence Standard met? There is a comprehensive complaint procedure that meets the National Minimum Standard. The procedure has been distributed to all service users, who know how to use it. Service users can raise any issues with their Care Pathway Facilitator, any other member of staff, the manager, any of the proprietors or via one of the service user meetings. There has been no complaint made to the home or to the NCSC about the home since the last inspection.Winnett CottagePage 20 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence, or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) YES which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists Key findings/Evidence Standard not assessed on this occasion. X Standard met? 0Winnett CottagePage 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Winnett CottagePage 22 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence Standard not assessed on this occasion. YES NO NO 10 0 X X Standard met? 0 10 XX X X XWinnett CottagePage 23 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence Standard not assessed on this occasion. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Winnett CottagePage 24 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Winnett CottagePage 25 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Winnett CottagePage 26 Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X 9 X 0 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X 370 Nursing X X XXX3 Key findings/Evidence Standard met? Staff are supported in their work through in-house training, supervision and clinical discussion groups. The Senior Liaison Officer oversees staff training by City & Guilds in Community Mental Health as this is regarded as being more comprehensive and pertinent to the work of the hostel that NVQ. Each member of staff has a training profile. Three members of staff are enrolling to undertake VNQ training at level 2. The manager and deputy are enrolling to undertake the Registered Manager Award training.Winnett CottagePage 27 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. 3 Key findings/Evidence Standard met? The current staffing establishment consists of a manager, a deputy manager, 7 care pathway facilitators and a housekeeper. All these posts are full-time. The home has currently 2 vacant staff posts and these have been advertised. Scrutiny of duty rotas indicate that 2 member of staff are deployed on duty for most part of the day although at times there is only 1 member of staff. The manager and deputy are on call. At night, 2 waking members of duty are deployed on duty. Vacant posts and staff absences are covered by 3 members of bank staff and 2 regular members of staff from an agency. The staffing are the same as at the last inspection. In view of the positive comments made by service users and of the inspectors observation of good care practices, staffing levels are deemed to be adequate to meet the needs of the current group of service users. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Psycare have made a range of appropriate policies and procedures available in the home. New staff are subject to a three-month probationary period that can be extended if required. Service users are not directly involved in the selection of staff. Staff files reveal that the requirements of the Regulations are being followed. The manager keeps a list of names and dates of staff CRB forms sent and received. A copy of the GSCC code of conduct is available to all members of staff. Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? Each member of staff has a training profile detailing all training received.Winnett CottagePage 28 Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Staff confirmed that they feel that they are well supported and that they receive regular supervision. Group staff meetings have also been planned and there will be an in-built process for the deputy to collate views, opinions and ideas put forward by the staff. Annual appraisals are not due yet. All staff have a copy of the staff handbook and this includes the grievance and disciplinary procedures.Winnett CottagePage 29 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care or equivalent. NO3 Key findings/Evidence Standard met? The manager has been registered with the NCSC since February 2004. He has twenty years management experience in the NHS and has been a manager since 1983. He also has six years experience of working in the independent sector. He has a wide variety of knowledge of psychiatric services and has clinical and managerial experience as a supervisor, supervisee and trainer.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 1 Key findings/Evidence Standard met? The manager advocates a holistic, non-judgemental approach to life in the hostel. He also operates an `open door policy to staff and service users alike. It was evident from discussions with staff that the processes of managing the home were open and transparent. Members of the management team of Psycare Hostels visit the home on a regular basis. However they do not produce a written report of the conduct of the home as per regulation 26. This must be in place.Winnett CottagePage 30 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems based on seeking the views of service users are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Younger Adults. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained up to date and accurate. 3 Key findings/Evidence Standard met? All statutory records scrutinised at this inspection were maintained in accordance with legislation. However, the monthly visits by the proprietors representative (required under Regulation 26) are not recorded (see also standard 38 ­ above).Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The manager has extensive knowledge of Health & Safety legislation and the deputy is the designated Health & safety Officer and all staff members have received appropriate training. Staff (and service users who cook for other service users) have been provided with food hygiene training. Policies and procedures cover aspects of environmental safety are in place. Risk assessments are completed whenever a safe working issue is identified. The accident book was examined.Winnett CottagePage 31 Standard 43 (43.1 ­ 43.7) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 0 Key findings/Evidence Standard met? Standard not assessed on this occasion.Winnett CottagePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition Nil CommentsComplianceLead Inspector Second Inspector Locality Manager DateAli Soobhany None Cathryn Bramham 29th March 2004Signature Signature SignatureWinnett CottagePage 33 PART DLAY ASSESSORS SUMMARY(where applicable) There was no Lay Assessor at this inspection.Lay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.Winnett CottagePage 34 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 3rd March 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the NCSC in response to provider comments: Winnett Cottage Page 35 Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by 7th April 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Winnett CottagePage 36 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I Mr Russel Fletcher of Winnett Cottage confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I Mr Russel Fletcher of Winnett Cottage am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: Hostel General Manager 15th March 2004 Russell FletcherPrint Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Winnett CottagePage 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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