Care Home: Windmill Lodge

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What the care home does well Service users and relatives spoken to and also responses received within relatives` surveys were overall very positive about the home, the staff and the care. Comments included; ` I can`t fault them (Re: Staff) one bit`, `Its very nice here we are well looked after`, ` We are really pleased, its very good. The care is there` (Relative),`Management and staff are always nice and friendly. They look after my mother really well..`, `The care home is lovely and clean and some one is always there if we need someone to talk to about things`` ` I do feel that the home is well run and looks after its clients well.` Senior staff assesses prospective service users` needs before they move to the home. Care plans address all service users` needs. Health care needs of service users are well met. Service users are treated respectfully by staff and their rights to privacy maintained. Family and friends can visit as they choose. Overall the food is healthy and nutritious. Service users are listened to and their concerns are taken seriously and acted upon. Service users are protected from abuse. Service users have their own en-suite rooms which are large enough and which they can decorate as they choose. The home is clean and hygienic throughout. The required number of staff hold or are undertaking the NVQ Level 2 in Care. Staff receive adequate training in order for them to be able to meet the needs of service users What has improved since the last inspection? All parts of care plans are now reviewed monthly. There have been improvements in the home`s medication systems to ensure service users are fully protected and they are supported where appropriate to take responsibility for their own medication. The home `s recruitment practice has been made more effective to protect service users. Health and safety issues have been addressed to protect service users and staff. What the care home could do better: The home needs to make sure all terms and conditions are fully completed with the required information before service users sign the document. There still needs to be improvements in respect to the home`s activity programme to ensure all service users are given opportunities for social stimulation and interaction. The home must offer effective end of life care that follows current best practice. Some improvements to mealtimes need to be made to ensure meals are served promptly and service users are not kept waiting for their food. The home must show that it is planning each year to improve all areas of the service in ways that service users and their relatives want. Service users and relatives must receive monthly statements of their personal finances if the home is supporting them to manage these. CARE HOMES FOR OLDER PEOPLE Windmill Lodge 115 Lyham Road London SW2 5PY Lead Inspector Ornella Cavuoto Key Unannounced Inspection 10:00 22 & 25th February 2008 nd 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 Lodge DS0000058177.V341404.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 Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windmill Lodge Address 115 Lyham Road London SW2 5PY 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) 0208 674 4940 0208 674 5466 grace.ale-olurin@excelcareholdings.com Windmill Healthcare Ltd Ms Grace Ebun Ale-Olurin Care Home 93 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability (0), Physical disability of places over 65 years of age (0) Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. There must be team leaders on every floor. Respite care must be limited to 4 beds on the ground floor and 4 beds on the first floor. Intermediate care must be restricted to the third floor only There must be a minimum of two nurses on shift on each of the first and second floors during the waking day and a minimum of one nurse on the third floor on each shift during the waking day. 9th November 2006 Date of last inspection Brief Description of the Service: Windmill Lodge Care Centre is a modern, purpose built care home run by Excelcare for 93 older people in Brixton. There are four floors with the ground floor offering residential care and the other three floors offering nursing care. There are eight respite beds in the home, which are limited to four respite beds on the ground floor and four respite beds on the first floor. There is a general store next to the home and Brixton shopping centre and station is a short drive one way from the home and about the same distance in the other direction is Streatham Hill shopping centre and station. The service user guide states the current range of fees is £391.61 per week for residential care, £559.13 for nursing care and £599.38 for frail elderly nursing care. Additional charges are made for things such as hairdressing and newspapers. The provider makes copies of the reports of the Commission’s inspections available in the reception area. Windmill Lodge DS0000058177.V341404.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 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection that took place over two days. The registered manager was present for the duration of the inspection. The inspection involved speaking to five care staff and one of the nursing staff. Nine service users were spoken to and also there were discussions with two relatives and two friends of service users that were visiting the home at the time the inspection took place. In addition prior to the inspection relative surveys were sent out and the home was required to complete an Annual Quality Assurance Assessment (AQAA) that provides information on how the home has ensured National Minimum Standards (NMS) have been met to secure positive outcomes for service users, areas for improvements and areas in which difficulties have been encountered in meeting NMS. Both these sources of information will be referred to within the report. Finally other methods used in the inspection process included a tour of the premises, observation and looking at records. What the service does well: Service users and relatives spoken to and also responses received within relatives’ surveys were overall very positive about the home, the staff and the care. Comments included; ‘ I can’t fault them (Re: Staff) one bit’, ‘Its very nice here we are well looked after’, ‘ We are really pleased, its very good. The care is there’ (Relative),’Management and staff are always nice and friendly. They look after my mother really well..’, ‘The care home is lovely and clean and some one is always there if we need someone to talk to about things’’ ‘ I do feel that the home is well run and looks after its clients well.’ Senior staff assesses prospective service users’ needs before they move to the home. Care plans address all service users’ needs. Health care needs of service users are well met. Service users are treated respectfully by staff and their rights to privacy maintained. Family and friends can visit as they choose. Overall the food is healthy and nutritious. Service users are listened to and their concerns are taken seriously and acted upon. Service users are protected from abuse. Service users have their own en-suite rooms which are large enough and which they can decorate as they choose. The home is clean and hygienic throughout. Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 6 The required number of staff hold or are undertaking the NVQ Level 2 in Care. Staff receive adequate training in order for them to be able to meet the needs of service users What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective and current service users have the information they need to make a decision about the home. Service users’ needs have been assessed by the home prior to admission. Terms and conditions were not in place for all service users and not all parts had been completed. EVIDENCE: The service has a comprehensive statement of purpose and service user guide that contains all the information required by regulation. This includes a breakdown of fees for the home including any nursing contribution that is to be paid and outlines what is not covered by the fees. This addresses the requirement stated in the home’s last report. There was evidence within service users’ files of a form signed by service users or a relative indicating they had received copies of both documents. Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 9 A sample of six personal files belonging to service users that were placed on each floor of the home was looked at. Five of the personal files belonged to service users that had been admitted to the home within the last three -four months. All contained evidence that a full needs assessment had been obtained from the referrer and also that the home had undertaken their own pre-admission assessment with service users to ensure that the home was a suitable placement and able to meet their individual needs. A random sample of terms conditions were checked for eleven service users and although the majority had been issued terms and conditions outlining their stay, there was no evidence for two service users that had been admitted to the home within the last three months of a terms and conditions having been issued or signed. The registered manager reported that the relatives to whom they were sent had yet to return the documents but as previously recommended it would be good practice to keep a record of when the documents were sent and of efforts made to get relatives to sign the documents. In addition, subject to a previous requirement not all the terms and conditions were fully completed with room numbers not having been specified, they had not all been signed by the provider as specified on the document and some had not specified the level of fees to be paid and by whom; either the service user themselves if it was a private placement or the local authority (See Requirements & Recommendations). Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, 9, 10 &11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users had a care plan drawn up that had set out health, personal and social care needs. Service users health care needs have in the main been well addressed and they have been well protected by the home’s medication policies and procedures. Service users have been treated respectfully and their rights to privacy upheld. Comprehensive ‘End of Life’ plans have yet to be drawn up with service users, relatives and representatives. EVIDENCE: Six personal files were looked at belonging to service users that were situated on all four floors of the home. All the files included a care plan that had addressed service users’ health, personal and social care needs. In addition, in respect to service users’ personal and social care needs each service user had a ‘Pre-admission Social Care Diary’ that had been completed with them and/or relatives, which provided good detail about service users’ individual personal preferences in respect to daily and personal care routines, food likes and dislikes and hobbies and interests. Yet, it was evident that this information had not always been used within care plans. It is recommended that the Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 11 information within the ‘Social Care Diary’ is used within care plans to ensure service users’ individual needs in these areas are fully addressed. All the files included a completed falls risk assessment and a manual handling assessment. Risk assessments that addressed other risks presented by service users’ needs were also in place. There was evidence that all risk assessments and care plans had been reviewed monthly as specified within NMS and generally changing needs and progress had been reflected. Furthermore, there was evidence that service users, relatives and representatives where appropriate had been involved in the care planning process and the home was seeking to involve relatives in reviews of care plans. Finally, subject to a previous requirement that the home must ensure after service users’ are admitted a six weekly review is held with the referrer to monitor the suitability of the placement and address any initial concerns, this was identified as met at this inspection with evidence seen that reviews had taken place (See Recommendations). In the main service users’ health care needs had been well met. It was evident from personal files that there had been liaison with a range of health professionals to ensure service users’ health care needs were addressed. These included a GP that regularly visits the home, podiatry and chiropody, speech and language, community psychiatric nurses, physiotherapy services, psychologists, dietician amongst others. In addition, all service users whose personal files were checked had risk assessments completed in respect to nutrition, pressure area care and continence and these had been regularly reviewed. Service users’ weight had been monitored monthly or more frequently where it had been assessed as being required and where weight loss had occurred prompt and timely interventions had been taken by nursing staff. Food and fluid charts that had been put in place for service users had been accurately maintained. In respect to pressure area care overall this had been addressed appropriately and although generally turning charts that had specified four hourly turning had been maintained accurately it was noted that there was frequently a gap between 6.00pm and midnight. It is recommended that staff are reminded of the importance of ensuring that times service users are turned are adhered to as specified within care plans (See Recommendations). In respect to medication, a sample of medication records was checked from all four floors. On the floors that provide nursing care only qualified staff administer medication. On the residential floor only staff that have done medication training and have completed a comprehensive work booklet drawn up by the provider on medication administer medication. In addition, all nurses have to complete an annual medication competency assessment of which evidence was seen. There was a list of signatories in place on all floors. All medication records that were checked were found to be accurate. Subject to a previous requirement that medication stock checking systems should be effective this was met at this inspection. There was evidence that medication was checked three times daily at the beginning of each shift to ensure early Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 12 identification of errors. Also, a running total of all medication that was not in blister packs had been maintained and stocks of medication that were checked corresponded to records. In addition, controlled drugs were checked and were found to be in order. In terms of cold storage of medication, temperatures of fridges had been recorded daily and these were within recommended limits of 2-8c. However, room temperatures that had been correctly recorded daily were noted to often be over the recommended limit of 25c on the first and second floors despite air coolers being used. It is advised this continues to be closely monitored and alternative ways to try to reduce the room temperature be considered if the temperatures remain high. Finally, in relation to a previous requirement that all service users are given the opportunity to self- administer their medication unless they have been risk assessed as not being able to do so was identified as met at this inspection. A medication risk assessment had been completed for all service users. One service user had been assessed as being able to take responsibility for their own medication. This had been agreed with the GP and there was evidence that regular spot checks had been undertaken to ensure the service user was self administering correctly. Staff interaction with service users was observed as being warm and respectful. All service users and relatives spoken to confirmed that staff were polite and service users stated they were happy with how they were supported by nursing and care staff and that their privacy was upheld. Responses within surveys received from relatives were also mainly very positive about staff. Comments included ‘ They treat her well and show her respect and they are aware of her age and that she is hard of hearing’, ‘The staff in the home care well for the residents in sometimes difficult circumstances’. All service users were observed as being very well dressed and groomed. The home has a hairdresser who regularly attends the home. This was also highlighted by responses within surveys, ‘Residents generally look clean and well cared for’. There was some information regarding service users’ ‘End of Life’ wishes and instructions and there was some evidence that relatives had been consulted but the plans varied in the detail provided and none had been completed comprehensively. It was evident that this was an area that needed more attention. The registered manager reported that they and the care manager of the home were still undertaking training in respect to the Gold Standards Framework for End of Life care to ensure the home operates in accordance with best practice in this area and that some of the nurses were still to commence this training. This should result in an improvement in the drawing up of plans with service users and relatives (See Requirements). Windmill Lodge DS0000058177.V341404.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 &15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a weekly activities schedule but it was not clear whether all service users were receiving sufficient opportunities for social stimulation and interaction. Service users have regular contact with family and friends and links with the local community have been maintained. Service users can make their own choices and are supported to exercise control over their lives. Meals that are healthy and nutritious are provided but meals need to be served more promptly to service users. EVIDENCE: The home has a weekly activities schedule in place that includes bingo, quiz, reminiscence, exercise, watching old films amongst others. The home also organises for outside entertainers to come into the home. There are two part time activities co-ordinators who have responsibility for organising the activities and entertainment. At the last inspection it was identified that although the co-ordinators had received some training they had not completed training in how to facilitate reminiscence work or how to conduct exercise with service users. At this inspection, there was evidence that one of the coordinators had undertaken a course in which they learnt about doing exercises with service users and both had done a reminiscence course. However, Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 14 although some service users spoken to confirmed that they had been involved in activities such as playing bingo, doing exercises and watching old films it was not clear that these were held regularly with individual service users reporting that they heard bingo was not taking place for a few weeks. Also, there was no evidence that reminiscence work with service users had taken place. The activities co-ordinators reported that they no longer maintained records listing the activities that were held and who had joined in. Instead, they reported they wrote an evaluation of service users’ participation in the monthly review section of their care plan covering ‘Social care needs and activities’. However, these did not give details as to which activities service users had been involved in and how often they had joined in. It was noted that on one of the days the inspection took place exercises was on the schedule for the morning but did not take place. The activities co-ordinator reported due to an injury they were unable to do the session but no alternative activity was arranged in its place. A bingo session was seen that was very well attended by service users from all floors. However, generally during the inspection service users were observed as spending a lot of time in the lounges watching television and due to a lack of records being maintained it could not be fully assessed that all service users were being given sufficient opportunities for stimulation and social interaction. There was some evidence that the coordinators did spend individual time with some of the service users from notes within personal files (See Requirements) There was evidence from service users’ personal files and also from speaking to service users that contact with relatives and friends had been maintained. There were visitors to the home throughout the inspection. Also, relatives and friends spoken to during the inspection stated they had been made to feel welcome by staff. One relative commented in a survey, ‘ …family and friends are made very welcome.’ In addition, service users have links with the local community with outside entertainers coming into the home and various religious representatives also attending the home to provide communion and to do services. Also, some of the service users are involved in an allotment project run by the local community. In terms of service users being allowed to exercise choice and control the home supports them to bring in personal possessions if they wish which was evident from rooms that were seen. Also, where appropriate service users can manage their own money. There is information about an advocacy service available to service users seeking independent advice and support. Service users’ meetings are held quarterly to give service users an opportunity to discuss different aspects of living in the home. One service user spoken to said about a meeting held recently, ‘They asked about the staff and food if we are happy’. Service users feedback about food was positive and they confirmed they received a choice. Also, although the home provides an African/Caribbean menu for service users, individual responses from relatives’ surveys indicated Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 15 not all service users with specific cultural needs were being met. It is advised that the home consult more closely with relatives and service users about this to ensure service users receive food they prefer to eat. During the inspection, the inspector was offered to eat lunch with the service users. The meal was tasty and nutritious and the mealtime was relaxed and unhurried. Staff provided service users requiring assistance to eat in an appropriate and respectful manner. However, it was noted on both days of the inspection that there was a delay from when service users were sat at tables and when meals were served of up to 25 minutes. This needs to be looked at so service users are not kept waiting for food for so long (See Requirements & Recommendations). Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and relatives considered their concerns would be listened to and acted upon. Overall, service users have been protected from abuse although some staff need to do refresher training in adult abuse. EVIDENCE: Service users and relatives spoken to all stated that they would know who to talk to if they had a complaint about the service and they were confident that their concerns would be acted upon. One relative commented how minor issues of concern that they had raised had been dealt with to their satisfaction. The home’s complaint policy meets with NMS outlining the stages and timescales for the process. A copy of the policy was placed on display in all service users’ rooms that were seen for easy accessibility. The complaints log of the home was checked. All complaints informal and formal had been logged. Since the last inspection fourteen complaints had been recorded that related to various issues including staff attitude, standards of care and staff behaviour. It was reported five complaints were substantiated. All the complaints had been thoroughly investigated with detailed records maintained. Appropriate action had been taken to address complaints and complainants had been informed of the outcome of the investigations in writing and within timescale in line with the home’s policy. There had been four concerns relating to adult protection since the last inspection that related to allegations regarding staff behaviour and standards Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 17 of care. These were appropriately reported to the local authority and thoroughly investigated by the home. Two of the concerns were not substantiated whilst one was partially substantiated and one was fully substantiated. There was evidence from the home’s training matrix that staff had completed training with regards to adult abuse. However, not all staff that were spoken to were clear about procedures to follow if abuse was suspected or identified. It was noted that some staff had completed their training approximately two years ago and it is recommended that it is arranged for all staff who last completed training in this area eighteen months – two years ago complete a refresher training course (See Recommendations). Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 &26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained, safe and homely and is also clean and hygienic. EVIDENCE: The home has been purpose built and therefore is suited for its stated purpose. It is spacious, bright and each floor has a lounge and dining area although the top floor lounge and dining area is quite small. All service users have their own rooms with en –suite facilities. Furnishings of the home are domestic in character to create a homely and warm atmosphere. On the days of the inspection the home was clean and hygienic. This was commented upon in some of the responses within relatives surveys, ‘…the home is very clean.’, The care home is lovely and clean…’, … ‘The home is always clean and comfortable for the residents…..’ Windmill Lodge DS0000058177.V341404.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 &30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is sufficiently staffed to meet service users’ needs. Staff have been supported to achieve a relevant qualification to ensure they are of a competent level to work with service users. The homes recruitment practices have protected service users. Staff have received adequate training in order to meet the needs of service users but annual appraisals have yet to be completed for all staff. EVIDENCE: At the last inspection concerns were identified that there were insufficient staff to meet service users’ needs. As a result a requirement was specified that an audit should be undertaken by the home comparing care hours to the number of staff hours and that a copy of this should be sent to CSCI. This was completed by the home and the audit, which was sent to CSCI demonstrated that there were sufficient staffing levels in the home. At this inspection, no concerns regarding service users’ needs not being able to be met due to a lack of staff were identified. Staffing levels were observed as being adequate. The registered manager reported that staffing is organised according to the number of service users and their dependency. Furthermore, concerns regarding staff working in the home that did not have adequate language skills to communicate effectively with service users and their families was not identified as a problem at this inspection. Staff were observed as well as those who were spoken to as speaking a good level of English. Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 20 It was reported that 72 of care staff have completed or were in the process of undertaking a National Vocational Qualification (NVQ) Level 2. Of the four care staff spoken to three had all achieved a NVQ. This exceeds the specified target within NMS that 50 of staff should have a relevant qualification. A sample of staff files was checked belonging to staff that had recently been employed by the home. It was found that the home had a robust recruitment procedure. All documents required by regulation were in place including an up to date Enhanced Criminal Record Bureau (ECRB) checks and two references. In respect to previous requirements; that two trained staff should interview job applicants, the home using POVA First checks as a matter of course as opposed to just emergency situations and that old Criminal Record Bureau (CRB) had not been destroyed were all identified as having been addressed at this inspection. A previous recommendation regarding Equal Opportunities forms being held separately from staff files to ensure they are anonymous had also been dealt with. There was evidence from the home’s training matrix and also in speaking to staff that they had undertaken relevant training in relation to mandatory topics such as manual handling, fire safety, health and safety and food hygiene. There was also evidence that staff had completed specific training to enable them to meet the needs of service users more effectively, for example in dementia, Mental Capacity Act training, care for the dying/End of Life care, catheter care, care planning amongst others. Newly recruited staff have to complete an induction work booklet that meets with Skills for Care specifications and evidence of this was seen in staff files that were checked. In respect to a previous requirement that all staff should have an individual training and development plan drawn up following an annual appraisal of their performance and training needs, this was identified as having been partially met at this inspection. Although appraisals and individual training and development plans had been mainly completed for nursing staff, care staff were still to have an appraisal carried out with them (See Requirements). Windmill Lodge DS0000058177.V341404.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): 31,33,35 &38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is efficiently run and managed. Generally the home is run in the best interests of service users but information obtained from customer satisfaction surveys still needs to be used more effectively. Service users finances are safeguarded but service users, relatives or representatives must be issued monthly statements. The health and safety of service users and staff are protected. EVIDENCE: The home is managed by a registered manager who has overall responsibility for the home. There is also a care manager who has responsibility for managing all clinical areas of the home. The registered manager is suitably qualified. They are a qualified nurse, have a diploma in Health Service Management and are presently working towards a masters in Health Service Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 22 Management (MBA). It was evident through the inspection that the registered manager was knowledgeable about all aspects of the running of the home including service users’ needs and was found to be approachable by service users and staff. As part of self-monitoring the home uses various tools to ensure standards within the home are maintained. A number of audits are carried out, for example to monitor pressure sores, care plans and as mentioned in respect to Standard 9 daily medication audits are done. Monthly provider (Regulation 26) reports and also a detailed monthly operational report that looks at all aspects of the running of the home are completed. In terms of the home’s Annual Quality Assurance Assessment (AQAA) submitted to CSCI prior to the inspection this had been completed to a good standard and provided detailed and accurate information about the home. There was also evidence that customer satisfaction surveys had been completed. This included a general survey undertaken with service users, relatives and professionals, a survey that specifically looked at food and one that had been completed in respect to respite care offered at the home. At the last inspection it was identified that despite the home completing the surveys there was no plan in place to analyse the data and make sure improvements are made before the next survey. Also, although there was a business plan for the home this did not include specific information about service users’ views of the home and how the home would develop and improve in response to those views. At this inspection the home’s action plan did include some information about the results of the food survey and the respite care survey to ensure service users views were addressed but it was evident that this was limited and that information from surveys still needed to be used more effectively to ensure that the home is run in best interests of service users (See Requirements). Service users’ money is protected by robust accounting procedures. The administrator holds accurate records of money held by the organisation and two staff sign for any transactions when service users cannot sign. A sample of service users’ records and monies were checked and these were all found to be correct. Yet, subject to a previous requirement that monthly statements should be issued to service users, relatives or representatives where appropriate this had not been met (See Requirements). Staff files that were seen demonstrated that staff have received regular supervision to ensure that all staff would receive at least six supervision sessions a year as specified within NMS. All the required health and safety documentation and checks were in place. A previous requirement that different fire call points are tested weekly was met at this inspection. The home carries out monthly health and safety audits and also had an up to date fire risk assessment in place. Windmill Lodge DS0000058177.V341404.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 3 X 3 X 2 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 3 X 3 Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP2 Regulation 5 Requirement Timescale for action 31/08/08 2. OP11 15 3. OP12 12 (1) (b) & 16 (2) (m) (n) 4. OP12 16 (2) (m) The Registered Manager must ensure that all parts of the service users’ terms and conditions are completed. (Previous timescale of 31/12/06 not met) The Registered Manager must 31/08/08 ensure that staff are trained in and the home operates such systems as the Gold Standard Framework and the Liverpool Care Pathway to fully support someone according to best practice when dying. (Previous timescale of 28/02/07 partially met) The Registered Manager must 31/08/08 ensure that appropriate stimulating group and individual activities are devised to respond to service users assessed needs. (Part of previous requirement: Unmet timescale 30/08/06. Timescale of 28/02/07 partially met) The Registered Manager must 31/08/08 ensure that service users exercise appropriately and as per DS0000058177.V341404.R01.S.doc Version 5.2 Windmill Lodge Page 25 5. OP12 6. OP15 7. OP30 8. OP33 9. OP35 care plans and records of this exercise are accurately maintained. Exercise must be offered by appropriately trained staff. (Previous requirement of 28/02/07 partially met) 12 (1) (b) The Registered Manager must & 16 (2) ensure that appropriate (m) & (n) reminiscence activities are offered by effectively trained staff. (Previous timescale of 28/02/07 partially met) 12(1)(a)& The Registered Manager must 16(2)(i) ensure that there is a minimal delay from when service users are sat down for meals to when the meal is served. 18(1)(a)(c The Registered Manager must ) (i) & (ii) ensure that individual training and development plans are drawn up following an at least annual appraisal of staff performance and training needs. (Previous timescale of 28/02/07 partially met) 24 The Registered Manager must ensure that there is an annual development plan based on the views of service users, their relatives and other stakeholders that shows how the home intends to improve and develop over the forthcoming year. (Previous timescale of 28/02/07 partially met) 13 (6) The Registered Manager must ensure that service users (or their relatives) who have their money managed by the organisation, are given the monthly statements of their account. (Previous timescale of 30/11/06 not met) 31/08/08 31/08/08 31/08/08 31/08/08 31/08/08 Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 26 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. 2. Refer to Standard OP2 OP7 Good Practice Recommendations The Registered Manager should ensure that records of efforts that have been made to get the service user or relative to sign the terms and conditions are kept on file The Registered Manager should try to ensure that the information contained in the ‘Pre-admission Social Care Diary’ for service users outlining for example their preferences in respect to personal care and daily routines is included within care plans drawn up. The Registered Manager should try to ensure that staff are reminded that service users should be turned according to the times specified on the chart and within care plans and this needs to be done consistently. The Registered Manager should try to ensure that all service users with differing cultural needs are consulted about the food they would prefer to eat and their needs met accordingly. The Registered Manager should try to ensure that all staff that last completed adult abuse training 18 months – 2years ago that they do a refresher course. 3. OP8 4. OP15 5. OP18 Windmill Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Lodge DS0000058177.V341404.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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