Care Home: Windmill House

Similar services:

• Fairfields Country Rest Home
• Poldhu
• Queensmount
• Trevaylor Manor
• Didsbury Court Rest Home
• Belma
• Hunters Care Centre
• Manor Lodge

What the care home does well Information made available about the home and their pre-admission assessment processes ensure that placement is only offered to those whose needs can be met. The people who live in the home can be assured their individual personal and healthcare needs will be appropriately met. Medication administration methods were unsafe but have been amended in line with safe practice. People who live in this home have the opportunity to participate in a range of activities and can spend their time as they wish. They are provided with wellbalanced and nutritious meals. People who live in this home, and their relatives, can be assured that any complaints they have will be listened to and acted upon and that they will be safeguarded from harm. Windmill House is a very comfortable, well furnished and well maintained home, set in beautifully kept grounds. It is equipped to meet the needs of older people. The home is warm, well lit and is kept spotlessly clean. The staff team are well trained and competent, so people who live in this home can be assured that the team will have the necessary skills to meet their care needs. Windmill House is well managed and run in the best interests of the people who live there. The home is safe and their health, safety and welfare is promoted and protected. What has improved since the last inspection? What the care home could do better: CARE HOMES FOR OLDER PEOPLE Windmill House Alveston Road Tockington South Glos BS32 4PH Lead Inspector Vanessa Carter Unannounced Inspection 26th February and 2nd March 2009 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windmill House Address Alveston Road Tockington South Glos BS32 4PH Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01454 413818 windmillhouse@live.co.uk Windmill Care Limited Mrs Katharine Rachel Collacott Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 37 persons aged 65 years and over requiring personal care 9th March 2007 Date of last inspection Brief Description of the Service: Windmill House is registered as a private residential care home providing accommodation and personal care for up to thirty-seven older people aged sixty-five years and over. The home is owned and operated by Windmill Care Ltd a company owned by Mr and Mrs Collacot. Mrs Collacot is the registered manager. Windmill House is situated in the hamlet of Old Down, close to the village of Tockington where there are shops and other village amenities. The home is on a bus route to the town of Thornbury approximately two miles away where there are a variety of services and facilities. Transport is provided by the home. The home is a period, detached house set in its own grounds, which has been extended. An additional new wing was built in 2004 that provided a further seven en suite rooms and additional lounge space. The original house has three floors with many character features. The more modern extension to the house is on two floors. The new wing is at ground level. A passenger lift and stair lift provide access to all floors. There are well-established gardens that offer sitting areas and level walks with attractive features. Most rooms overlook the garden and communal areas have aspects into the garden. The cost of placement can be discussed with the Manager. People funded through the Local Authority have a financial assessment carried out in accordance with Fair Access to Care Services procedures. Local Authority or Primary Care Trust charges are determined by individual need and circumstances. General information about fees and fair terms of contracts can be accessed from the Office of Fair Trading web site at www.oft.gov.uk http:/www.oft.gov.uk . Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means the people who use this service experience good quality outcomes. This key inspection was unannounced and took place over two days. A total of 7 hours were spent in the home. Evidence to form the report has been gathered from a number of sources:• Information provided by the Home Manager in the Annual Quality Assurance Assessment (AQAA) • Talking with the deputy manager, and the Home Manager on day two • Talking with the care staff on duty • Observations of staff practices and their interaction with the people who live in the home • A tour of the home • Case Tracking the care of a number of people • Talking with a number of the people who live in the home • Looking at some of the homes records • Information supplied in CSCI survey forms, completed by people who live in the home • Information supplied by a GP who has patients who live in the home. What the service does well: Information made available about the home and their pre-admission assessment processes ensure that placement is only offered to those whose needs can be met. The people who live in the home can be assured their individual personal and healthcare needs will be appropriately met. Medication administration methods were unsafe but have been amended in line with safe practice. People who live in this home have the opportunity to participate in a range of activities and can spend their time as they wish. They are provided with wellbalanced and nutritious meals. People who live in this home, and their relatives, can be assured that any complaints they have will be listened to and acted upon and that they will be safeguarded from harm. Windmill House is a very comfortable, well furnished and well maintained home, set in beautifully kept grounds. It is equipped to meet the needs of older people. The home is warm, well lit and is kept spotlessly clean. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 6 The staff team are well trained and competent, so people who live in this home can be assured that the team will have the necessary skills to meet their care needs. Windmill House is well managed and run in the best interests of the people who live there. The home is safe and their health, safety and welfare is promoted and protected. What has improved since the last inspection? What they could do better: We issued one immediate requirement during the inspection as we saw unsafe medication administration practice. The registered person must ensure that medications are always administered safely and in accordance with the homes medication policy. We will be following up compliance with this requirement by visiting the home again. We also made a number of recommendations that we would like the home to follow. Three documents need to be reviewed and updated – the Statement of Purpose, the Complaints Procedure and the policy on the Protection of Vulnerable Adults. We were told that all the homes policies and procedures are in the process of being reviewed. The emergency lighting system must be checked on a consistently regular basis and records kept. Two bedroom carpets need to be stretched and refitted properly. They could cause a trip or a fall. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information made available about the home and their pre-admission assessment processes ensure that placement is only offered to those whose needs can be met. EVIDENCE: The Statement of Purpose and homes brochure are reflective of the service and details the facilities that are available in the home. The statement of purpose needs to be reviewed and updated. This is because some of the information is old and out of date. It contains all the necessary information as detailed in the National Minimum Standards but must be reviewed on a regular basis - the contact details for the Commission for Social Care Inspection were not correct. We were told by the owner/manager, that this document, and all the homes policies and procedures are in the process of being reviewed and rewritten. People who were spoken with during the inspection said that they were provided with enough information to make an informed choice about what Windmill House has to offer. Many people had previously lived in their own homes in the local area and therefore already knew about the home. These Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 10 documents are available in the home, along with the previous inspection reports. Each resident is provided with a contract (a residency agreement) and where the local authority is part-funding the placement, a providers contract is set up. Of the 10 people who completed CSCI survey forms, all stated that they had been provided with a statement of terms and conditions (a contract), and information about the home. One comment made on a survey form was “My son made the decision for me to move here because I had had a fall and was in hospital. He made all the necessary financial arrangements”. The home manager will visit any prospective person who wishes to live at Windmill House, so that an assessment of their needs can be made. Placement at the home is not offered to any person whose needs cannot be met. The home currently has no vacancies, and we were told that there is always a waiting list of people who want to live in the home. When there is a vacancy, people would be asked to visit the home, see the room they would occupy and meet the other people who live there. Evidence was available to show that one person who had recently moved to the home, had been visited in the hospital ward, where a long term needs assessment form had been completed, that identified their individual needs. This document is then used as a basis for the person’s plan of care. Two people, who had lived at the home for sometime, told us that they had chosen this home because of its local reputation for providing good care. Placements are arranged on a month’s trial basis with a review meeting, taking place at the end of this period with all necessary parties. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in this home can be assured their individual personal and healthcare needs will be appropriately met. Medication administration methods were unsafe but have been amended in line with safe practice. EVIDENCE: Care planning documentation for three people were looked at - one being the file for the person who had recently moved to live in Windmill House. A “Residents Long Term Needs Assessment and Care Plan” had been prepared for each person and provided a very detailed record of how each person wished to be looked after. Personal preferences were recorded. The sample looked at showed that each persons care needs are looked at on an individual basis, and details are recorded of how these needs were to be met. It is evident that these arrangements are in agreement with the person as either they or their representative are asked to sign the plans. People spoken with during the course of the inspection confirmed that they were involved in the care planning process and that they were looked after in the way that had been agreed. Nine of the 10 people who completed CSCI survey forms said that they “always” received the care and support that they needed. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 12 The home maintains a record of all visits by GP’s and other healthcare professionals. The district nursing services are regular visitors to the home and assist with dressings, catheter care and any blood tests. Other healthcare visitors include chiropody services, dentists and opticians. One person was supported to attend a local dental surgery on the first day of inspection and we were told that where possible, visits out of the home are made to attend any medical appointments. Those people spoken with during the inspection said that they had been able to retain the services of their existing GP as they had lived locally but others had been helped by the manager to register with one of the local GP practices. GP’s will be contacted to visit people whenever there is a need rather than on a planned basis. One GP commented that the service “always” acts upon, and seeks advice, to improve individual’s health care needs. We looked at the homes procedure for the ordering, receipt, storage, administration and disposal of medications. During the inspection we observed unsafe ways of administering the lunchtime medications, and we asked the member of staff to immediately stop this way of working. We were told that this was the method used by all staff who administer medicines, even though this was not in line with the homes medication policy. An immediate requirement notice was issued and when we visited the service again on 2 March 2009, we were advised what measures had been put in place to ensure that safe working practices were adhered to from now on. We will be monitoring that this safe practice is consistently followed. People are cared for with respect to their dignity and their privacy. Personal care is provided in private and care staff were observed to knock on bedroom doors before entering, and speak to people respectfully. People were nicely dressed and their clothes were well cared for. During the course of the inspection, all the staff were observed interacting well with the people they were looking after, being friendly and attentive – there was a respectful level of friendly banter. “The home ‘cares’ in every possible way” and “I am very well looked after by all the staff” were two comments made on CSCI survey forms. The GP who completed a CSCI survey form said that the service “always” respected individual’s privacy and dignity. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who live at this home have the opportunity to participate in a range of activities and spend their time as they wish. They are provided with wellbalanced and nutritious meals. EVIDENCE: A variety of different activities are arranged for people to take part in, and they are able to choose whether to participate or not. Care staff will take it in turns to organise activities and have rota time throughout the week to do this. We observed staff sitting with people and having a singing session, or sitting and chatting about life events. One person said that they like to go out for a walk every day, weather permitting and also had talking books delivered. Some people chose to remain in their bedrooms whilst others spent their time in one of the two lounge rooms. There is a weekly ‘exercise class’ and three people said they looked forward to it but sometimes only observed what was going on. There is a plentiful supply of library books, some large print, and these are changed on an eight weekly basis. Trips are arranged into the nearby town of Thornbury every other week using the homes minibus. Everyone who completed a CSCI survey form said that there was “always” or “usually” activities that they could take part. One person wrote “I choose not to take part in the arranged activities but like to walk and join in the outings”. We Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 14 were also told that birthdays are always celebrated, as are any seasonal events. People are supported and encouraged to maintain contract with family and friends and to go out for trips with their relatives. If people are able to go out independently this is encouraged. Some people go out to local clubs to maintain contacts with old friends and to continue with favourite pastimes. People were observed moving around the home independently within the limits of their individual abilities. Some people spent their time in one of the two lounge areas, whilst others were in their bedrooms. One person said “I have my favourite chair. I like to sit here and watch the TV”. It is evident that people are able to choose how they spend their time and are content in their surroundings. The home has an open visiting policy and visitors are able to visit at any reasonable time of day. They are asked to sign in at the visitor’s book. On the day of inspection the lunchtime meal was shepherds pie with vegetables and potatoes, followed by a fruit pudding. We were told that all meals are home cooked and locally sourced produce is always used. There is a six weekly menu plan and we saw that roast meals are served twice a week and that chicken, fish and vegetarian meals are provided. At tea time a variety of snack meals and sandwiches are served. All 10 people who completed CSCI survey forms said that the meals were “always” good. People spoken with after lunch, said that the meal had been tasty and well cooked. Family or friends are able to join their relatives for the midday meal, upon arrangement. The midday meal is seen as a sociable and important part of the day’s activities and generally most people have their lunch served in the dining room. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in this home, and their relatives, can be assured that any complaints they have will be listened to and acted upon and that they will be safeguarded from harm. EVIDENCE: The complaints procedure is included in the statement of purpose and service user guide and a copy is given to all persons and their families. This document needs to be updated with the correct details for the Commission, should people, or staff, want to contact us. People spoken with during the course of the inspection said they would talk to the manager or care staff if they were not happy about anything – “I am perfectly happy and have absolutely nothing to worry about” was one person’s comment whilst another said “the manager is very approachable and the staff are thoughtful”. All the CSCI survey forms that were completed indicated that people and relatives were aware of the procedures to follow if they had any complaints. Since the last inspection the home has not received any complaints – the manager wrote in the AQAA that they consider any complaints or concerns raised as an opportunity to improve their service. CSCI have received no complaints about this service. The home has a policy and procedure to ensure that the people who live there are safeguarded from any form of abuse, and also the South Gloucestershire Council ‘No Secrets’ guidance. The information contained in the homes policy is misleading in that it states that “all reports of abuse however minor should immediately be investigated and acted upon by the person-in-charge”. This is Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 16 not in line with the South Gloucestershire protocols as an internal investigation could in some circumstances contaminate an investigation by other agencies, for instance the police. The manager is fully aware of the locally agreed protocols to follow should any concerns be raised but needs to reflect this in their policy. We were told that all policies and procedures are in the process of being reviewed and updated. Some staff have attended Safeguarding Adult training delivered by South Gloucestershire Council whilst others have received in-house training. Those spoken with during the course of the inspection demonstrated good awareness of adult abuse issues and of their responsibilities in protecting people from harm. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Windmill House is a very comfortable, well furnished and well maintained home, set in beautifully kept grounds. It is equipped to meet the needs of older people. The home is warm, well lit and is kept spotlessly clean and tidy. EVIDENCE: Windmill House is situated in the hamlet of Old Down, close to the village of Tockington where there are shops and other village amenities. The home is on a bus route to the town of Thornbury approximately two miles away where there are a variety of services and facilities. The home is a period, detached house set in its own grounds. It has been tastefully extended to provide additional accommodation. The home is surrounded by two acres of wellestablished gardens that are kept to a very high standard. There are patio areas where people can sit out in the warmer weather and level walking areas and pathways. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 18 The living accommodation is arranged over three floors, and there are two staircases, a passenger lift and a stair lift that provide access to all floors. The home is well maintained throughout, very comfortably furnished and tastefully decorated throughout. The communal areas are all located on the ground floor. There are two large lounges, one overlooking the large lawn area at the back of the house, and the other is the TV room. There is one dining room and the tables are all set out hotel style and laid with table linen and small flower arrangements. There are toilet and bathing facilities located throughout the home, in sufficient numbers to meet people’s needs. Some of the bathrooms have assisted bathing facilities whilst others have a normal bathroom suite. The home has a stair lift that goes up to the second floor in one part of the home and a passenger lift that goes to all three floors in the main part of the house. Grab rails are fitted in bathrooms and toilets and we saw specialist beds, raised toilet seats and hoisting equipment in place where needed. Other items of equipment and aids would be sourced as needed. There is level access in to the home. All bedrooms have a direct dial telephone and are fitted with a call bell system. Each of the 37 bedrooms have en-suite facilities, and all are for single occupancy. The seven bedrooms in the new wing all look out onto the main garden area and have French windows that opened out onto the patio. All of the bedrooms were seen and each had been personalised to reflect individual tastes. The carpet in two of the bedrooms needs to be stretched and re-fitted as they could potentially be a hazard to a person with reduced mobility or poor vision. The home was warm, well lit, spotlessly clean and tidy, and free from any malodour. The CSCI survey forms completed by people who live at the home and relatives indicate that the home is always “fresh and clean”. This was so on the day of the inspection. The environmental health officer awarded the kitchen a five star rating in February 2008. There are currently plans awaiting planning that will include refurbishment of the laundry room. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team are well trained and competent so people who live in this home can be assured that the team will have the necessary skills to meet their care needs. EVIDENCE: The staffing levels are arranged according to the dependency levels of the people who live in the home and on the day of inspection there were five staff on duty. The staff rota’s evidenced this to be the normal allocation of staff. We were told that that there are four staff in the afternoon and evenings, and two waking members of staff overnight. We were told that staffing levels are adjusted as and when necessary and to take account of any events that are planned. The home has designated staff for catering and domestic duties. Staff spoken with, were enthusiastic about their role and able to demonstrate a good awareness of each person’s specific care needs. 60 of the current staff team have gained a qualification in care at least at NVQ Level 2 and an additional 17 are currently working towards the award. Some staff have also obtained NVQ Level 3. This shows a real commitment by the service to have well trained staff and this means that people can be assured they will be well looked after. Agency staff are not used and this means that people will be cared for by staff who are familiar with their care needs. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 20 The staff files for three staff members were looked at to determine the procedures followed. Recruitment procedures include the completion of an application form, attendance for an interview, two satisfactory written references, and CRB and POVA1st clearance, prior to employment. These measures will ensure that the right people are employed for the home. The induction - training programme for new care staff meets Skills for Care specifications and the completed programme for one new care worker was seen. One worker said that they had ‘shadowed’ a senior worker for several shifts whilst they were getting used to the job. All mandatory training is included in this training period and we were told this involves fire safety, first aid, moving and handling training and food hygiene. Windmill House does not have a training plan for the year as such however arranges mandatory training courses as and when members of the staff team need updates. We saw that other training sessions have been arranged for a number of staff in the next two months and these include mental capacity act training, deprivation of liberty safeguards (DOLS), dementia awareness, care ambassador training and specific disease management awareness. One person who lives at Windmill House, who had completed a CSCI survey form commented that they wanted staff to have additional training specific to their needs and so it was commendable to see this already being addressed. Staff told us that the manager was very receptive to suggestions about additional training. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Windmill House is well managed and run in the best interests of the people who live there. The home is safe and their health, safety & welfare is promoted and protected. EVIDENCE: Mrs Katy Collacott is the registered manager and co-owner of Windmill House and has run the home since 1998. She is a level 1 registered nurse, and has obtained an NVQ Level4 in Management and the Registered Managers Award. She is well qualified and experienced in the care management field. There is also a deputy manager who has been in post for three years and they are also qualified to NVQ Level 4 in Management. From discussions with both people who live in the home and the staff who were on duty, it is evident that the manager is approachable and keen to seek Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 22 views and suggestions on how the service is delivered and could be improved. “They would find it very difficult to improve” was written on one CSCI survey from. One person spoken with during the inspection said they had regular resident’s meetings and that the staff “listen to us and if they can they do what we ask”. The most recent quality questionnaire (November 2008) showed that in all areas bar one people are very satisfied with the service, and the care and support that they receive at Windmill House. Measures have already been put in place to address the area where the home only scored an 84 satisfaction score. This survey is repeated on an annual basis. The home holds monies for a small number of people and records of transactions in and out of each of the accounts are maintained, along with receipts. The records were not looked at in this inspection. The majority of people who currently live at Windmill House are able to look after their own funds or they rely upon family or friends. All records required during the inspection process were readily available, apart from personal staff files. For this reason the inspector met with the home manager on a second day. All the records that the home are required to keep are well maintained. The home’s records are either kept in the manager’s office, or in an alcove area of the kitchen. Policies and procedures are in place to ensure that the health, welfare & safety of both staff and the people who live in the home, are promoted. We were told that all policies are in the process of being reviewed and where necessary, amended. Staff will receive health and safety training and are expected to have an understanding of the relevant policies and procedures. There are established systems in place for staff to communicate any maintenance or repairs that are required. The home is well maintained throughout and apart from the two specific carpets that need attention, no health and safety issues were noted. Safety checks are not being completed on a consistently regular basis. Some staff said that they had recent fire safety training, however we were told that practice fire drills appear to only happen infrequently. Staff spoken with knew what the fire procedure is and what they should do. The fire alarm system is checked on a weekly basis but checks on the emergency lighting are not being made on a regular basis. The lights had been checked in the last month and were functioning. All the health and safety testing of electrical equipment, stair lifts and hoisting equipment were up to date. Where appropriate, a risk assessment around manual handling is undertaken a safe system of work is devised so that staff know what action they have to take. Since most people at Windmill House are fully ambulant, these assessments are not completed for all. Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 2 Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement Immediate Requirement The registered person must ensure that the homes medication policy is adhered to at all times. This is so that the potential for medication errors is eliminated. Timescale for action 19/03/09 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 OP1 Good Practice Recommendations The Statement of Purpose needs to be reviewed and updated to make sure it contains all the correct information. The Complaints Procedure needs to be updated with the correct information. This is so people are able to contact the Commission if they want to. 2 OP16 Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 25 3 OP18 The protection of vulnerable adults policy (POVA) needs to reflect the locally agreed protocols so that staff do not follow the wrong procedures. The carpets in bedrooms 5 and 23 need to be stretched and refitted securely. This is so that the danger of people tripping is reduced. 4 OP24 Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Windmill House DS0000003337.V374327.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!