Inspection on 08/02/05 for Winnett Cottage

Care Homes For Adults (18 ­ 65)Winnett Cottage111 Hertford Road Bragbury End Stevenage Hertfordshire SG2 8SHUnannounced Inspection8th February 2005 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 Tel No: 01442 878504 Fax No: 01442 861152Name of registered provider(s)/company (if applicable) Psycare Hostels Name of registered manager (if applicable) Russell Fletcher Type of registration Care Home No. of places registered (if applicable) 10Category(ies) 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 9th February 2004 No NO 14/09/04 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 38th February 2005 10:00 am Louise Bushell None None NoneID Code161584Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionNone Anne Skinner ­ Lead Care Pathway Facilitator. Russell Fletcher ­ Registered Manager.Winnett CottagePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings 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: D.1. D.2. D.3. Compliance with Conditions ( if 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 Commission for Social Care Inspection (CSCI) 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 CSCI in respect of Winnett Cottage. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) 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 CSCI 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 · 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. 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. The home currently supports nine men, with one vacant place available. The home has received a number of referrals and assessments of referred persons are occurring. 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 was a positive inspection in terms of the care and support offered at the home. Service users spoken to during the inspection were very positive about the staff and the care and support offered. A number of requirements have been made namely regarding administrative systems within the home and the environment. The home offers a flexible person centred service in which all service users spoken to expressed a level of satisfaction. Choice of Home (Standards 1-5) 4 Standards were assessed, 4 were met. 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. The management and the staff within the home are adequately trained and experienced to meet the need of the service users currently residing in Winnett Cottage. The home is able to offer a two-part service tailored to meet individual needs. The home aims to provide a full integration into community living. There is a comprehensive Statement of Purpose and Service User Guide in place to provide all required and relevant information to any prospective service user. The home has a detailed referrals procedure in place that offers trail visits to the home, single over night stays and a reviewing process for the service user and the home. All service users have an individual tenancy contract drawn up following a trial and review period. Individual Needs and Choices (Standards 6-10) 5 Standards were assessed, 4 were met. The service users appeared to live as independently as possible with discreet support offered where necessary. Service users are involved in the day to day running of the home from domestic chores to making meals. The care plans and individual service users files are in the process of being updated currently. Many care plans were missing from individual files and/or had not been completed. A requirement has been made that all service user files and care plans are completed and audited as part of the supervision progress to ensure completion and sound monitoring of progress and works to be competed. Service users participate in house meetings to discuss any concerns and issues that they have regarding the running of the home. Lifestyle (Standards 11-17) 6 Standards were assessed, 4 were met. Some service users are able to undertake paid employment, with employers using the homes risk assessments as part of the process. Practical skills are encouraged and service users had decorated some areas of the home recently. The garage had been converted into a gym and leisure area that appeared popular. A holiday is being arranged and the service users are able to choose if they attend. All Service users utilising Windsor House receive appropriate professionally validated interventions, counselling and therapy. Specialist interventions are available if required. All service users are able to choose whom they see and when: and can see visitors within their rooms and in private. Service users are able and empowered to meet people and maintain personal relationships with people of their choice. Advice and specialist guidance is provided to support service users to make appropriate Winnett Cottage Page 6 decisions. Personal Healthcare Support (Standards 18-21) 4 Standards were assessed, 2 were met. The home maintains positive links with the local surgery and clinical teams. All service users have access to regular health checks. The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework. Consent is sought by the service user for the administration and retention of medication. Records are kept of all medications received into the home or disposed to ensure safe working practices. All staff that administer medication receive detailed training prior to being deemed competent. Requirements have been made with regards to the storage and administration of medication. Concern, Complaints and Protection (Standards 22-23) 2 Standards were assessed, 1 was met. There had been no recorded complaints since the last inspection, the home does have a complaints policy, but this needs to be updated to show that the Commission for Social Care Inspection can be contacted at any stage of making a complaint. Staff receive Adult Abuse Training from Hertfordshire County Council Adult Care Services and have a Whistle Blowing policy. Environment (Standards 24-30) 4 Standards were assessed, 1 was met. All service users have a single bedroom and all bedrooms meet the minimum space standard requirements, one would be suitable to accommodate a wheelchair user if needed. Service users had decorated some areas of the home and a new kitchen had just been fitted. The exterior of the home has also been repainted since the last inspection. The premises had previously been used as a home for older people, some of the furniture and furnishings from the previous owners were being used by the current service user group, these were showing signs of wear and tear and a requirement was made for the service provider to provide new furniture and furnishings in those areas. Door wedges were being used to hold some doors open, an immediate requirement was made. Staffing (Standards 31-36) 4 Standards were assessed, 3 were met. Staff have a good understanding of the service users assessed needs and many staff had worked with these service users before they became resident at the home. The home has now made a commitment to NVQ training for staff. Requirements were made in respect of staff personnel files that did not contain all the information required by the Care Homes Regulations 2001. Conduct and management of the home (Standards 37-43) 4 Standards were assessed, 3 were met. Policies and procedures examined during the inspection were seen to be comprehensive in detail and were accessible to all. The staff spoken to at the time of the inspection felt that the openness and the approach of the manager was effective and fair. The manager felt that his management style was inclusive and positive promoting a solid team approach. Requirements have been made with regards to the accurate recording of health and safety monitoring records within the home.Winnett CottagePage 7 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. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action Action is being taken by the Commission for Social Care Inspection 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 StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Winnett CottagePage 8 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 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, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action That the service provider must provide new furniture and furnishings at the home. The service provider is to forward a timetabled programme of refurbishment to the commission. This requirement has been carried forward By from the last inspection and remains outstanding. A new timescale has been 20th April issued for compliance. 2005. Wood panelling in the first floor bathroom requires replacing. The shower hose in the first floor bathroom requires replacing.116(2)(c)YA24217(2) Schedule 4 YA34 19(4)(b) Schedule 2That all staff files contain the information required by the Care Homes Regulations 2001.This requirement has been carried forward 20th March from the last inspection and remains 2005. outstanding. A new timescale has been issued for compliance.ByWinnett CottagePage 9 315 (2) (a)&(b)YA6The registered manager develops and agrees with each service user an individual Plan By which may include treatment and rehabilitation, describing the services and 20th April facilities to be provided by the home, and how 2005 these services will meet current and changing needs and aspirations and achieve goals. The registered manager must ensure that all service users have adequate risk assessments held within their individual files for anticipated areas of high risk. Dates of implementation and review must be held to ensure accurate reviewing occurs. 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 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. The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract. Any imposed restrictions must be detailed within the service users individual plan. Service users must be supplied with suitable window coverings to promote and protect their privacy and dignity.By 20th April 2005413(4)(b)& (c)YA912(1)(b) 5 12(2) 13(4)(c) YA16YA15By 2nd April 2005612(4)(a) 16(2)(c)By 2nd April 2005YA18713(2)YA20The registered manager must comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. From 8th February Gaps in recordings must not be present on 2005 & MAR sheets. Henceforth Instructions stated on the MAR sheet must duplicate those detailed on the prescription and pharmacists instructions.Winnett CottagePage 10 822(7)(a)YA22The registered manager must ensure that the complaints policy is updated to reflect that the Commission for Social Care Inspection can be contacted at any stage by the complaint. The registered manager must ensure that all communal areas are free from storage and that they can be utilised for the assigned purpose. The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. Door wedges must not be used within the home. Doors can only be kept open by devices approved by the Fire Safety Officer. Accurate records of fridge and freezer temperatures must be recorded in compliance with relevant food hygiene regulations. Adequate records of Fire Safety checks within the home must be maintained.By 30th March 2005 By 7th March 2005923(2)(i)(l)& (m)YA241023(4)(c)(iii)YA42By 7th March 20051113(4)(c)YA42By 7th March 2005 By 7th March 2005 By 7th March 200517(2) 12 Schedule 4(14) 23(4)(c)(i) YA4213YA42Repairs to the fire panel must occur.Winnett CottagePage 11 RECOMMENDATIONS 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). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * That the home seeks authorisation for the administration of homely remedies within the home that are stated on the homes policy. This should then be held within the service users file. The use of homely remedies should be managed within the home and implemented as the homes policy states, thus being agreed as part of an holistic package of care.1YA20* 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 12 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 NO YES YES NO YES NA YES YES YES YES YES YES NO NO NO YES NO YES 6 X 2 NO NO YES YES 8 1 08/02/05 10AM 5.75Winnett CottagePage 13 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) 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 14 Choice 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 and 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. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Key findings/Evidence Standard 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. 3 Key findings/Evidence Standard met? The primary function of Winnett Cottage is to provide a rehabilitation programme aimed at supporting all service users in community and independent living skills. The home provides on going reviewed assessment at each stage of the cycle to ensure appropriate levels of support are provided and tailored to individual levels. Assessments are conducted and completed by these who are appropriately trained to do so. Evidence of ongoing assessments were viewed at the time of inspection. New service users are only admitted to the home following an assessment process. The home has a comprehensive admissions procedure in place to support the divers needs of the service users.Winnett CottagePage 15 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. 3 Key findings/Evidence Standard met? The management and the staff within the home are adequately trained and experienced to meet the needs of the service users currently residing in Winnett Cottage. The home is able to offer a two-part service tailored to meet individual needs. The home aims to provide a full integration into community living. Persons residing within the home are able to access staffing resources and support 24 hours a day; staff are based directly on site. The home continuously monitors and reviews the progress of the service users within the home and if at any stage it is felt that further support is required the service user can utilise resources as determined by the individual need. Specialist intervention within the home are demonstrably based on current good practice and reflects relevant specialist and clinical guidance. 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. 3 Key findings/Evidence Standard met? The home has a detailed referrals procedure in place that offers trial visits to the home, single over night stays and a reviewing process for the service user and the home. All service users have an individual tenancy contract drawn up following a trail and review period.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. 3 Key findings/Evidence Standard met? There is a comprehensive Statement of Purpose and Service User Guide in place to provide all required and relevant information to any prospective service user. The home has a detailed referrals procedure in place that offers trail visits to the home, single over nights and a reviewing process for the service user and the home. All service users have an individual tenancy contract drawn up following a trial and review period. The contract is held on their individual files and is signed by the manager and the service user. Where support is required to sign, representation and the use of advocacy service can be utilised.Winnett CottagePage 16 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. 2 Key findings/Evidence Standard met? The registered manager and staff team develops and agrees with each service user an Individual Plan, which includes 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. All plans are service user focused and are aimed at increasing service user motivation and participation into community living. The care plans and individual service users files are currently in the process of being updated. Many care plans were missing from individual files and or had not been completed. Some care plans had not been reviewed and were missing any implementation date and signature of the service user and or representative. A requirement has been made that all service user files and care plans are completed and audited as part of the supervision progress to ensure completion the sound monitoring of progress and works to be competed. The Plan sets out how current and anticipated specialist requirements will be met, for example through positive planned interventions; rehabilitation and therapeutic programmes; structured environments; adaptations and equipment and one-to-one communication support. The plan is drawn up with the involvement of the service user together with family and/or relevant agencies and specialists. The home assigns a key worker to all service users. The home has a sound system in place to ensure that at all times the needs of the service user are met and the role of the key worker is maintained. The role of the key worker is full understood by all service users within the home.Winnett CottagePage 17 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? Staff respect service users rights to make decisions. That right is limited only through the assessment process, involving the service user, and as recorded in the Individual Service User Plan. Service users are encouraged and empowered to manage their own finances; where support is required it is offered and well documented for the reasons why. Service users are encouraged to participate in local independent advocacy groups / selfadvocacy groups and/or to access further appropriate support if desired. Staff support all service users in the provision of information, guidance, assistance and communication support to empower them to make decisions about their own lives. The home is currently working with PohWer Advocacy Services.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? The service users within the home are able to have access to all policies and procedures upon request. Service users participate in house meeting to discuss concerns and issues that they have regarding the running of the home. Minutes from these meetings are taken and a member of staff supports the process and acts as a link between the service users team and the staff team. Issues fed through to the management team are discussed and actions are taken as appropriate. The home operates an open door policy and any concerns can be discussed freely, openly but confidentially with all members of the team. Service users were able to confirm that they have received feedback about outcomes of their involvement and participation.Winnett CottagePage 18 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. 2 Key findings/Evidence Standard met? Staff support all service users to take reasonable risks as part of independent living lifestyles. One service user was observed having adequate risk assessments in place. Those observed covered areas of risk such as deterioration of mental health state, violence to self and others, sleep disturbances, inappropriate sexual behaviour, self-neglect and physical health and absconding. The home has completed some generic risk assessments. The home is currently in the process of reorganising and updating all service user files and risk assessments. A requirement has been made that all care plans are completed for all service users and risk assessments are completed and held on individual files for all anticipated areas of risk, including service users smoking in their own bedrooms. The home must assess risk of new admissions according to health and social services protocols and in discussion with the service user and relevant specialists; this must then be agreed, signed and recorded in each individual plan and reviewed. Risk assessments must state an implementation date to ensure accurate reviewing of the document occurs. 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. 3 Key findings/Evidence Standard met? 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. Service users and their families have access to the homes policy and procedures on confidentiality and on dealing with breaches of confidentiality. Staff explain and/or ensure service users understand the policy.Winnett CottagePage 19 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? Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. This was observed during the inspection in the manner and the approach of the staff to other service users within the core home. Service users have opportunities to learn and use practical life skills including user-led training. This is namely achieved through the identification and goals within their individual plans, which are inturn all individual and user focused. All Service users utilising Windsor House receive appropriate professionally validated interventions, counselling and therapy. Specialist interventions are available if required.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 help service users to find and keep appropriate jobs, continue their education or training, and/or take part in valued and fulfilling activities. Service users can continue to take part in activities engaged in prior to entering the home, if they wish, or re-establish activities if they change localities. All service users are supported in gathering relevant information regarding employment, further education, employment skills and benefit advice if required. Some service users have an activities plan on their care plan which they have agreed and signed, this is aimed at promoting motivation and user participation and integration into community living.Winnett CottagePage 20 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. 3 Key findings/Evidence Standard met? See Standards 11 & 12. Staff enable service users integration into community life through: i. Knowledge about, and support for, service users to make use of services, facilities and activities in the local community (e.g. shops, library, cinema, pubs, leisure centres, places of worship, cultural centres); ii. Awareness or service users rights of access to public facilities under the Disability Discrimination Act 1995; iii. Maintaining a neighbourly relationship with the community; iv. Ensuring information and advice are available about local activities, support and resources offered by specialist organisations; and Ensuring access to transport ­ local public transport, accessible taxis, dial-a-ride, support to use it, to enable service users to pursue their chosen lifestyle and activities. 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? Staff ensure that service users have access to, and choose from a range of appropriate leisure activities. Service users are encouraged and supported to pursue their own hobbies and interests. See Standards 11, 12 & 13.Standard 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). 2 Key findings/Evidence Standard met? Staff support service users to maintain family links and friendships inside and outside the home. Family and friends are welcome within the home and are encouraged however, on agreement with the individual. All service users are able to choose whom they see and when: and can see visitors within their rooms and in private. Service users are able and empowered to meet people and maintain personal relationships with people of their choice. Advice and specialist guidance is provided to support service users to make appropriate decisions. See Standard 16 with regards to restrictions on visitors.Winnett CottagePage 21 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). 2 Key findings/Evidence Standard met? The daily routines within the home promote independence for all service users, using a person centred approach at al times. Staff were observed to interact with all service users well and it was clear that mutual respect was held within the home for both staff and service users. Service users are able to receive visitors within the home; a visitors policy is in place. Following discussions with a member of the management team it was determined that there are restrictions for visitors and the service users with regards to private meetings within the home. A communal second lounge is available, however is currently being used for storage. A requirement has been made for the room to be used for its purpose. The inspector was informed that visitors are unable to meet in the service users bedroom for prolonged periods of time. Any restrictions must be agreed within all service users care plan. A further requirement has been made that this be documented for all service users. 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 fully assessed on this occasion.Winnett CottagePage 22 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 procedures 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. 2 Key findings/Evidence Standard met? Staff are able to provide a flexible and person focused approach to the care that is provided within the home. The service user and the staff within the home predetermine the provision of care. All aspects of support to be offered are well documented and clear guidelines are in place to support the service user and the staff team. Following discussions with a group of service users it was determined that many of them are still awaiting appropriate window coverings to be made available for their rooms to promote and maintain their dignity. A requirement has been made that these are purchased and erected within a period of time 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) X03 Key findings/Evidence Standard met? The home maintains positive links with the local surgery where all service users are registered. Clinical teams liaise with the GP surgery to keep them informed of about the treatment and change in medication for service users. All service users have access to dental, sight and hearing tests. No service users had been admitted to accident and emergency since the last inspection. Minor accidents were recorded in the homes accidentrecording book.Winnett CottagePage 23 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. 2 Key findings/Evidence Standard met? The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework. Consent is sought by the service user for the administration and retention of medication. Records are kept of all medications received into the home or disposed to ensure safe working practices. All staff that administer medication receive detailed training prior to being deemed competent. The home is currently using the Nomad system for the safe administration of medication. The local pharmacist dispenses the medication fortnightly. On inspection of the medication being retained within the home, it was determined that on one occasion the instructions given on a MAR sheet were different to those stated on the label of the medication box. This causing an increasing risk of maladministration to the service user. Gaps were also identified in the MAR sheets. The registered manager has been asked to investigate these recorded occurrences. Some service users in the home are able to self medicate and the records reflected this. The home has a policy regarding this area. Risk assessments have been drawn up and are held on the medication file. It is recommended that these also be retained directly on all service user files for a consistent approach within the home. The home has a policy and a procedure regarding the safe use and storage of homely remedies within the home. Homely remedies are determined within a discretionary list and clear guidelines are set stating that there should be a letter of authorisation signed by the hospital / doctor / GP. The inspector observed a homely remedy not listed on the discretionary list being used. The home has been advised to seek authorisation for the administration of such homely remedies within the home that are stated on the homes policy. This must then be held within the service users file. The use of homey remedies must be managed within the home and implemented as the homes policy states, thus being agreed as part of an holistic package of care. 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. 3 Key findings/Evidence Standard met? Staff and service users within the home are supported to discuss and deal with issues surrounding death, dying and bereavement. All service users have a funeral plan within their care pan and appropriate support has been provided for drawing up these arrangements.Winnett CottagePage 24 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 timescales 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 CSCI Percentage of complaints responded to within 28 days X X X X X X X 2 Key findings/Evidence Standard met? The home holds a comprehensive and informative complaint procedure and policy. The home has recently reviewed the administrative management of complaints within the home and the new system appears to be well organised and easily accessible. It was noted that the complaints procedure had recently been updated, however it states that complaints will only be passed to the Commission for Social Care Inspection, following completion and the complainant not being satisfied with the outcome of the complaint. A requirement has been made that this is amended to ensure that at any stage an individual is able to pass their complaint directly to the Commission for Social Care Inspection without any input from the home, staff or Board of Directors.Winnett CottagePage 25 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) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX3 Key findings/Evidence Standard met? Robust procedures for responding to suspicion or evidence of abuse or neglect (including whistle-blowing) ensure the safety and protection of service users, including passing on concerns to the Commission for Social Care Inspection in accordance with the Public Interest Disclosure Act 1998 and Department of Health (D.H) guidance No Secrets are in planr. Staff spoken to at the time of the inspection had a sound knowledge of the Whistle Blowing policy and the procedures to follow.Winnett CottagePage 26 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. 2 Key findings/Evidence Standard met? There was a large lounge with a television and music system, a dining room and kitchen. A smaller lounge is available upstairs for service users and visitors; currently this is being used for storage. See Standard 16. The garage had been converted to provide a gym and leisure area for service users. Service users have agreed the smoking and non-smoking areas of the hostel. The home has recently purchased a new tumble dryer. The kitchen has recently been refitted and works appear to have been completed to a high standard. The exterior of the home has recently been repainted. Several of the bedrooms seen during the inspection were in need of new furniture including chairs and beds, which are now very old and worn. Following the last inspection plans have not been received detailing proposals for renewal. A further requirement has been made for the service provider to forward their proposals to Commission for Social Care Inspection to address this issue. The home must have a planned maintenance and renewal programme for the fabric and decoration of the premises with records kept. Some communal areas of the home had recently been redecorated and were brighter and more welcoming. Wedges were still being used to hold doors open in some areas of the home, an immediate requirement was made. The bathroom facilities within the home are in need of redecoration and upgrading. Following discussions with the management team there are plans in place to evaluate the two shower cubicles in place. It was noted these were extremely dated, small and unsteady. Wood panelling in one of the bathrooms requires replacing along with one of the shower hoses.Winnett CottagePage 27 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 This standard is met in terms of room size. YES NO NO 10 0 0 0 Standard met? 3 10 XX X X XWinnett CottagePage 28 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 Please refer to standard 24. Standard met? 2Standard 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. 2 Key findings/Evidence Standard met? The home currently has a large number of toilet and bathroom facilities available to all service users that are conveniently located for all. See Standard 24 for further comments.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 29 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 infection, 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 30 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. 3 Key findings/Evidence Standard met? During the inspection it was noted that the staff spoken to support the main aims and values of the home, understand and implement the homes policies and procedures, and know how their work, and that of other staff (including key workers), promoted the main aims of the home. Staff have a clear understanding of their role within the home and were able to identify and demonstrate sound working practices within the homes ethos and good practices principles.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. 9 Key findings/Evidence Standard met? The home has an effective staff team in place in sufficient numbers with appropriate skills to meet and support the service users within the home. Records show that staff levels are of a satisfactory level and ratio to meet the service users needs. Regular staff meetings occur within the home and records were seen. There is a low use of agency staff within the home and staff take on over time as and when required to ensure consistency within the home. All staff received regular training. The company, Psycare Hostels, has a Senior Liaison Officer in post who co-ordinates all training and development for the staff. New development plans and performance appraisal files have been introduced for all the staff. Once fully functioning this system will be sound. The Registered Manager is currently completing his NVQ Registered Managers Award and anticipated completion is July 2005. The remaining staff have all commenced their NVQs and following notification form the company, achievements of standard is anticipated by July 2005 for all staff.Winnett CottagePage 31 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. 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 X X X 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 X Nursing X X XXX3 Key findings/Evidence Standard met? The ratios of care staff to service users must be determined according to the assessed needs of residents. Currently the numbers of staff on duty is satisfactory and meets requirements. Records show low usage of agency and when agency is used, a core team are identified to ensure continuity. Regular staff meetings occur within the home approximately one every 6 weeks. The staff on duty are offered core mandatory training, which is reviewed. See Standard 32. 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. 2 Key findings/Evidence Standard met? Staff files did not contain the information required by the Care Homes Regulations 2001, shortfalls included references, copies of birth certificates and identification and one staff member was working at the home without a CRB. Requirements were made.Winnett CottagePage 32 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? See Standard 32 for comments.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? Standard not assessed on this occasion.0Winnett CottagePage 33 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 [by 2005]. YES3 Key findings/Evidence Standard met? The current registered manager Winnett Cottage has had over twenty years experience of working in the field of mental health care and is a qualified and registered mental health care nurse and is currently completing the NVQ Level 4 Registered Managers Award. He has been responsible for and has managed nursing aspects of several units in general and forensic Psychiatry settings with experience in both hospital and community based settings.Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The manager of the home was present toward the end of the inspection. The staff spoken to at the time of the inspection felt that the openness and the approach of the manager was effective and fair. The manager felt that his management style was inclusive and positive promoting a solid team approach.Winnett CottagePage 34 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 Adults (18-65). 3 Key findings/Evidence Standard met? Policies and procedures observed throughout the inspection were seen to be comprehensive in detail and were accessible to all.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. 0 Key findings/Evidence Standard met ? Standard not assessed on this occasion.Winnett CottagePage 35 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. 2 Key findings/Evidence Standard met? At the time of the inspection it was reported that the Fire Panel was showing a fault. This had been reported to the appropriate company, however, this still requires repairing as they are awaiting a part. The fire systems within the home were still working safely and adequate to meet and protect all individuals within the home. The inspector was informed that due to the recent refurbishment of the kitchen the cleaning monitoring, fridge temperature records and other in house du-diligence checks were not being completed routinely. The inspector was assured that routine checks would now recommence. A requirement has been made. This includes the weekly checking of fire alarm points within the home. Other health and safety records were observed and appeared to be in order. 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 36 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector DateLouise BushellSignature SignatureRegulation Manager Helen PettengellPublic reports It should be noted that all CSCI inspection reports are public documents.Winnett CottagePage 37 PART DD.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 8th February 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: Winnett Cottage Page 38 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. D.2 Please provide the Commission with a written Action Plan by 29th March 2005, 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 39 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of 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 D.3.2 I of 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:Print 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 40 Winnett Cottage / 8th February 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000038688.V210241.R01© This report may only be used in its entirety. 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