Inspection on 06/06/05 for Winthorpe Residential Home

This inspection was carried out on 6th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Winthorpe Residential Home 21/01/09

Winthorpe Residential Home 01/08/07

Winthorpe Residential Home 21/07/07

Winthorpe Residential Home 04/10/06

Winthorpe Residential Home 19/10/05

Winthorpe Residential Home 28/09/04

Winthorpe Residential Home 29/06/04

Winthorpe Residential Home 09/02/04

Winthorpe Residential Home 10/12/02

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Winthorpe Residential Home 84 Westcotes Drive Leicester Leicestershire LE3 0QS Lead Inspector Keith Charlton Unannounced 6 June 2005 at 3.30pm The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Winthorpe Residential Home Address 84 Westcotes Drive Leicester Leicestershire LE3 0QS 0116 2332107 0116 2339170 Mrs P Smith Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs P Smith Care Home 17 Category(ies) of LD - Learning Disabilities - 17 registration, with number of places Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home is able to admit the person of category LD(E) named in variation application number V10279. Date of last inspection 28/9/04 Brief Description of the Service: Winthorpe Residential Home is registered to provide care to up to seventeen adults with learning disabilities. The home is a three-story Victorian house situated close to the centre of Leicester. Service users are accommodated in one single and eight shared rooms. In addition to their rooms, service users have access to two lounge / dining rooms and a kitchen. There is a wellmaintained garden to the side of the property. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Inspection. The Registered Manager was present on the first inspection day; the two Deputy Managers were present for the second day. Planning for the Inspection included reading the Pre-Inspection Questionnaire completed by the Manager and the previous Inspection Report. No Comment Cards were returned by residents or their families. The Inspection took place between 15.50 and 19.50 inspection of records and direct and indirect observation of care practices. The Inspector spoke with six residents, two members of staff, the Registered Manager and the Deputy Managers. The Inspector completed the Inspection with the Deputy Managers on 17/06/05, which included a tour of the building. What the service does well: Relationships between service users and staff appeared generally very positive. Service users said that they liked living in the Home and they thought staff were friendly towards them and that the food was good. Care plans had detailed information as to service users interests and decisionmaking issues. Staff have read Care Plans for service users. Service users can help with domestic tasks if they wish e.g. making drinks. Staff know what to do if abuse is suspected or alleged. The staff try to ensure that service user bedrooms are personalised and homely. The Home looked generally clean and tidy. Service users said that they like the food. The Management organises annual holidays for service users which service users said they look forward to. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: To review institutional practices such as going to the tea trolley for drinks and queuing outside the office for medication, and replacing them with more homely, individual practices. To make sure that staff always ask service users to do things in a friendly and encouraging way and not tell them to do things in a direct manner. To ensure staff have read the Policies and Procedures to ensure consistent practice. To make sure that Agency staff are inducted in the challenging behaviour Policy. To always supply a dessert for service users at lunch and teatime. To inform service users that they can have seconds of food or drink if they wish. To review calling service users ‘lads’ and ‘lasses’ to avoid treating them as children, and using their first names instead. To ensure that one full meal as a minimum is supplied per day instead of two ‘snack’ meals (this only occurred on one day of the menu). To make sure that all areas of the Home are kept odour free. To make sure that all areas of the Home are kept free of obstructions to ensure fire safety. To have three care staff on all daytime and evening shifts. To do a Risk Assessment for all radiators and provide covers where necessary to make sure service users are protected from burning. To review furniture, décor and carpets to upgrade the Home to make it more attractive, based on service users preferences. To have a combined Management and care staff rota so that it is clear who is on duty at any time. To increase service users outings to places where they would like to go. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Assessments ensure that all aspects of service users lives are known and can be provided for. EVIDENCE: Care Management assessments were available for the service users who were chosen for the purposes of case tracking (looking in depth as to how they live their lives). Records indicate that they had been involved in the assessment process where possible. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,9 Staff know Service users needs and risks have been identified. EVIDENCE: Individual plans were available for service users who were chosen for the purposes of case tracking. The plans that were inspected were generally clear and comprehensive though there were some appendices missing, e.g. for sexuality and disposition - the Deputy Manager has e mailed the Inspector to say they have now been found. Records indicate that they have been reviewed on a regular basis and that, where possible, service users had signed them. Management have produced a policy on risk taking & risk management, which states that staff members will support a service user’s right to take risks as part of an independent lifestyle. The individual plans that were inspected contained details of any risks that had been identified. Staff said they had read service users care plans. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 Service users participate in activities of their choosing and have a right to pursue personal relationships. EVIDENCE: One of the service users chosen for the purposes of case tracking attends day centres during the week and also has a job in a local hospital doing domestic tasks which he enjoys. A second stated that she enjoys going into the city centre on the bus. Service users stated that they are able to maintain contact with their families and friends and that the Home would welcome any friends they brought to the Home. The Statement of Purpose indicates that visitors are always welcome. The Management have produced policies on relationships / sexual relationships, which support a service user’s right to develop and maintain appropriate friendships. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 12 Service users said that they were attending a club that evening which they enjoyed. A number of service user said they had been out during the day, two service users working – one in a charity shop and one in a hospital. The Registered Manager said that service users going out on their own were subject to the risk assessment process to ensure their safety, as some service users need supervision when they go out. There were a number of comments received that some service users would like to have more frequent outings, e.g. to the zoo, ten pin bowling, farm, seaside etc. The deputy Manager said that this is in hand as it is discussed at service user meetings and that outings are to be increased. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 Service users are satisfied with the personal support they receive. EVIDENCE: The individual plans that were inspected contained details of any personal support and equipment that is required and of service users’ preferences regarding their care. Service users stated that they could choose when to undertake various activities of daily living – getting up and going to bed, having a wash etc. The individual plans that were inspected contained details of any healthcare needs that had been identified and of any action that was necessary as a result. Records indicate that a range of healthcare professionals have been involved in the care of individual service users when necessary. A service user described how he was currently receiving treatment at hospital. It was observed that service users queued for their medication outside the office. It is recommended that this practice ceases and instead medication is issued at the dining table. The Deputy Manager said this would be changed. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Records and practices in the home ensure service users are safe. EVIDENCE: The complaints procedure is set out in the Statement of Purpose – this needs to be slightly altered so that it states that anyone wanting to make a complaint can go to the Commission for Social Care Inspection first if they wish. The Deputy Manager has e mailed the Inspector and sent an amended procedure but this still needs this minor alteration. A separate complaints book is to be kept. Service users again stated that they do know who to speak to if they are concerned about anything. Minutes of monthly service user meetings were available for inspection. The Registered Manager has a copy of the local multi-agency policy and procedures for the protection of vulnerable adults plus written policies on protection, the acceptance of gifts, aggression towards staff, physical intervention, the management of service users’ money & financial affairs and whistle blowing. Staff were asked as to the whistle blowing procedure and were aware of all the steps to take. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 The facilities are beginning to look somewhat dated and in need of modernisation. EVIDENCE: Service users are accommodated in a three-story Victorian house situated close to the centre of Leicester and within easy reach of a range of local amenities. Service users indicated that they are generally happy with the Home’s facilities. Two plastic garden chairs were used as dining chairs – the Deputy Manager said this was temporary as chairs were being repaired. Two unused gas fires were causing a partial obstruction on the second floor – these were moved. There were odouress carpets on the second floor in a bedroom and the area outside. The Deputy Manager said they would be steam cleaned within a day and the Deputy Manager has e mailed the Inspector to say they have now been cleaned. Bathrooms were locked for safety reasons according to the Deputy Manager (toilets were still available) though it was agreed that this would be reviewed to see if currently it was still a problem. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 16 The Deputy Manager said the Home’s facilities were being looked at with a view to improvement. A cover was needed on bed rails for one service user to prevent possible injury. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34 Staffing levels are generally satisfactory. Safe recruitment practices are not always followed. EVIDENCE: This inspection has taken into consideration the number of staff hours recommended by the Department of Health. The home has a minimum of two staff on duty throughout the day but generally has three. The Deputy Manager stated that normally the Home would have three staff but there were a small number of occasions where there were two. It was agreed that normally there would be three staff on as there is one service user who is always in bed, and certainly there would always be three staff when the two service users currently in hospital come back. (The home has reviewed its staffing levels to ensure that they meet the needs of service users as the previous Inspection Report noted that there were a number of evenings on the rota where there appeared to be two staff members on duty after six o’clock in the evening (i.e. at a time when service users have returned to the home and when they may wish to undertake social activities). The Home’s rota was confusing as there was a Management rota and a separate record in the diary as to care staff on duty without stating their hours. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 18 Staff records contained two written references and a copy of a Criminal Records Bureau disclosure though no Criminal Records Bureau / Protection of Vulnerable Adults number for Agency workers. Staff members stated that they had received a copy of the General Social Care Council’s Codes of Conduct. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Generally Health and Safety risks are well managed. EVIDENCE: Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 20 Staff members have received training on subjects such as fire safety, Moving and Handling , first aid and food hygiene with certificates seen. It was agreed there would be in house training on dealing with challanging behavior. The Deputy Manager stated that there is no current need to train staff regarding infection control. The home’s fire records were inspected and found to be up to date. The home has a health and safety policy. Risk assessments regarding a number of identified hazards were available for inspection. The Deputy Manager is to review these to ensure they cover all issues – use of ladders, availability of personal hygiene products etc. Every member of staff has received their own copy of the home’s policies and procedures. This is to be commended though staff said they had not yet read all of them – this is recommended. Radiator covers have not been fitted which could be a risk to service users. The Registered Manager needs to ensure that all radiators are Risk Assessed and covers provided where necessary. Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 x x 3 x x Standard No 31 32 33 34 35 36 Score x x 3 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Winthorpe Residential Home Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 42 Regulation 13.4 Requirement The Registered Manager needs to ensure that service users cannot scald themselves from hot radiators, Timescale for action 18/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 23 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Winthorpe Residential Home C51 S6448 Winthorpe V231632 060605.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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