Care Home: Windward Way

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What the care home does well People`s needs are assessed before they move into the home so they can be confident their needs will be met there. Activities take place, which people have chosen and enjoy doing to enable them to have a fulfilling lifestyle. The home is good at supporting people to keep in touch with their friends and relatives so that they don`t lose relationships that are important to them.People enjoy the food at the home and said, "The food is very good". There are good procedures to listen to people if they have concerns or worries and keep them safe from possible harm. Staff know people who live in the home well and are friendly to them. People said, "The staff are brilliant." Medication is being managed well so that people stay healthy. What has improved since the last inspection? Plans that explain how to care for people and help them stay safe and healthy are better written so that people`s needs are understood and met. A lot of work has been done to make the home look better and homely. Rooms have been redecorated and new equipment and furniture has been provided so that people live in a more comfortable environment. The patios in the gardens have been made bigger to give people who use wheelchairs more space to move around. Staff have had training to help them care for people and assist them to stay safe and well. The staff team have begun to review the way the home is run so that people who live there and their families have a say in what works well and what needs to improve so that people have a better lifestyle. This is called quality assurance. Regular health and safety checks are made so that equipment is well looked after and safe for people to use. CARE HOME ADULTS 18-65 Windward Way 170-174 Windward Way Smith`s Wood Solihull West Midlands B36 0PS Lead Inspector Julie Preston Key Unannounced Inspection 16th January 2008 09:30 Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 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 Windward Way DS0000066539.V356576.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 Adults 18-65. 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. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windward Way Address 170-174 Windward Way Smith`s Wood Solihull West Midlands B36 0PS 0121 779 6059 F/P 0121 779 6059 mikeklymko@lonsdale-midlands-limited.co.uk enquiries@lonsdale-midlands-limited.co.uk Lonsdale (Midlands) Limited 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) Nicola Jane Doughty Care Home 12 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (1), Learning disability (12), Physical disability of places (12) Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service may continue to accommodate two named service users within existing numbers who have learning disabilities with added dementia needs. 15th January 2007 Date of last inspection Brief Description of the Service: 170-174 Windward Way consists of three adjacent, domestic style bungalows. Each bungalow has four single bedrooms. The homes are located a residential area of Smiths Wood, a suburb of Solihull and provide care and accommodation to twelve younger adults with learning and physical disabilities. The home has a variation of registration for two service users who are above the age of 65 years to enable them to remain in the home. Local amenities including Woodland Parks, and shops are within walking distance. Chelmsley Wood shopping centre is approximately one mile away. Each home has a communal lounge, kitchen/diner, assisted bathroom, separate toilet, and four single bedrooms. Bedrooms vary in size and layout; there are no en-suite facilities. Each home has an individual area of garden at the rear. These are generally well maintained, although not well suited to the needs of people with impaired mobility. The sloped grassed area of bungalow 174 is not safe for use by wheelchair users and others who have restricted mobility, although additional space has been provided by the extension of the patio area. There is an adequate supply of lifting aids and pressure relieving equipment in each bungalow. The layout of each bungalow are virtually the same, there are no dedicated rooms for storage of large equipment. CareTech are the registered providers and are responsible for staffing and maintaining the premises. The charges range from £900.00 - £1300 per person per week, to which individuals contribute a set amount from their welfare benefit. Chiropody, hairdressing and papers/magazines are of varying prices and are not included in the fee rate. CareTech allocate funding to each person for payment of activities, holidays and outings. Windward Way DS0000066539.V356576.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. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. Prior to the fieldwork visit taking place a range of information was gathered to include notifications received from the home and a questionnaire about the home. The questionnaire is called the Annual Quality Assurance Assessment (AQAA). The visit took place over one day and staff and people who live at the home did not know that we were coming. Three service users were “case tracked” and this involves discovering individual experiences of living at the home by meeting or observing them, discussing their care with staff, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files and health and safety records were reviewed. The inspector looked around the building to make sure that it was warm, clean and comfortable. There were no immediate requirements after this visit. This means that there was nothing urgent that needed to be done to make sure people stayed safe and well. What the service does well: People’s needs are assessed before they move into the home so they can be confident their needs will be met there. Activities take place, which people have chosen and enjoy doing to enable them to have a fulfilling lifestyle. The home is good at supporting people to keep in touch with their friends and relatives so that they don’t lose relationships that are important to them. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 6 People enjoy the food at the home and said, “The food is very good”. There are good procedures to listen to people if they have concerns or worries and keep them safe from possible harm. Staff know people who live in the home well and are friendly to them. People said, “The staff are brilliant.” Medication is being managed well so that people stay healthy. What has improved since the last inspection? What they could do better: The service user guide, which gives people information about the home, has some parts that need updating to make them accurate. Sometimes staff do not write down what people have done during the evenings and at weekends to show that people are leading a meaningful lifestyle. Some health care records had not been filled in to show that people had received treatment and medication that they need to stay healthy and well. Windward Way DS0000066539.V356576.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. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is made available to people before they visit the home so that they can make an informed choice about whether to move in. People’s needs are assessed before they move into the home so they can be confident their needs will be met there. EVIDENCE: The home has a statement of purpose and service user guide, which are made available to people who live there and their relatives. Both documents explain the services and facilities available in the home and the terms and conditions of the person’s stay there. Pictures have been used to complement written information, which should assist some people to understand the content of the service user guide. The service user guide was observed to contain some minor information that was not relevant to Windward Way and named another home instead. The details for contacting the CSCI were incorrect. The guide should be reviewed to make sure that people have accurate information about the home and the services provided. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 10 There have been no new admissions since the last inspection and there are currently no vacancies. There are systems in place to ensure that individuals’ needs are assessed before they move into the home and that people have an opportunity to visit and stay over prior to making any decisions about whether to move in. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are effective systems of care planning and risk assessment in place to enable peoples’ needs to be understood and met. People that live in the home receive good support to make choices and decisions about their lifestyles. EVIDENCE: The care plans for three people were sampled. Each contained information about how staff are to support people to meet their communication, social, spiritual, health, personal care, dietary and mobility needs. The care plans had been reviewed within the last six months to ensure they continue to be relevant to individuals’ needs. Staff had signed care plans to confirm that they had read them, which should make sure that people receive the care they need consistently. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 12 Some people who live at the home have specific needs with regard to the way they communicate. Speech and Language therapy guidelines were observed which detailed the most effective way to communicate with people; staff were seen to follow this guidance by using communication passports (a document that explains how the individual communicates) and pictures to help individuals make decisions about activities that had been planned. As at the last inspection there was a range of risk assessments within the files sampled including, dependency, moving and handling, nutrition, falls and continence as well as general risk assessments. For any identified risks there were corresponding care plans stating how the risk was to be minimised by staff. Risk assessments sampled had been reviewed on a regular basis to make sure they remain relevant to people’s current needs. There were no rigid rules or routines in the home. People were seen to spend time in their rooms, take part in activities and spend time quietly in the lounge watching DVDs. People had breakfast and lunch at varying times and moved freely around their home. One person commented, “I choose what I do and when I do things. I don’t do anything I don’t want to.” Staff members demonstrated good understanding of people’s needs and how individuals communicate choice. A member of staff explained that where people did not use speech to communicate the team observed facial expression and body language as an indicator of enjoyment of an activity or routine, which aided future planning. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 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 the home experience a meaningful lifestyle that promotes their independence and is reflective of their individual needs. There were no restrictions on visitors to the home within reasonable hours. The catering arrangements at the home meet the needs of the people living there. EVIDENCE: People’s activity preferences had been recorded in their plans of care. Daily records were sampled to check that people had regular opportunities to take part in things they enjoy doing. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 14 Records showed that people undertake many activities such as having foot massage and manicures from a visiting beauty therapist, cooking, arts and crafts, music, attendance at local colleges, shopping, singing and dancing. Some records had not been completed in sufficient detail to describe what people had been doing at weekends and during the evenings. It is recommended that records be maintained so that people who live in the home continue to have access to a range of activities that meet their preferences as part of a meaningful lifestyle. One person talked about some of the things he likes doing and said, “I like it when we have parties and a drink. Good fun. I’m having a massage later, it’s nice”. The inspector was shown photograph albums of people’s holidays, which staff commented had been a great success. It was evident that people had taken part in a variety of experiences during their holidays such as visiting the Sea Life centre, watching a firework display and jousting tournament. One person said he was very much looking forward to going on holiday this year and had begun to plan what he would wear and take with him. The registered manager confirmed that CareTech pay for staff support during the person’s holiday, although the person would have to meet some costs. The registered manager went on to say that this would be explored with the individual’s advocate so that the individual had support from a source external to the registered provider to agree a reasonable contribution. The home is good at supporting people to keep in touch with their friends and relatives. Within the care plans sampled there was information about peoples’ relatives birthdays, so that cards and presents could be sent. The home has a visitor’s policy and the manager commented that relatives have regular contact either by telephone or in person. Menus and records of food consumed by individuals were sampled to establish that a balanced and varied diet is provided that meets peoples’ needs and preferences. A range of food had been offered including Sunday roasts and soft consistency meals, which is reflective of service users cultural and healthcare needs. People are supported to make food choices by looking at photographs that have been taken of meals that have previously been cooked in the home. Two options are available at each mealtime and people’s preferences are recorded in their plans of care. One person said, “The food is very good”. The registered manager commented that dining tables were on order that would give greater seating capacity so that people could receive support from staff to eat their meals more comfortably. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 15 Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are effective systems in place to meet peoples’ personal and health care needs. Medicines are generally well managed so that people receive their medication in a planned and safe manner. EVIDENCE: Two personal and health care plans were sampled at this visit. There was some good information about individuals’ personal care needs and preferences, which staff clearly understood so that people receive care in a manner they need and like. Staff spoken to during this visit were aware of the need to offer personal care in private to maintain peoples’ dignity. Both male and female staff are employed, which is reflective of the gender of the current group of people living in the home. Same gender care is offered Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 17 where possible and always where this is needed to meet individuals cultural needs. Records showed that people have regular appointments with healthcare professionals such as dentists, GPs, Speech and Language Therapists and Psychologists and the outcome of this contact had been documented so that staff had accurate information about individuals’ state of health. One exception was noted with regard to recording chiropody treatment. In one case no records of treatment were available and in another no records had been maintained since 2005. Two staff members stated that the people had received chiropody treatment on a regular basis, however the records had not been completed. It is strongly recommended that records are kept up to date so that it can be evidenced people are receiving healthcare services that meet their individual needs. People’s healthcare needs had been well monitored. A range of records were seen to monitor individual’s weight, bowel movements and fluid intake. It was positive to note that prompt action had been taken to respond to people who appeared unwell. Daily records sampled showed that where an individual showed signs of illness, an appointment was made with the GP the following morning. The home is in the process of updating Health Action Plans for everyone who lives there. A Health Action Plan is a document that describes what the person needs to do to stay healthy and well. The staff member responsible for leading Health Action Planning reported that the staff team had received training from Solihull Care Trust to enable them to contribute more effectively to the planning process. Within the healthcare records sampled, each person had had an annual medication review to ensure that prescribed medicines continued to be appropriate to their individual needs. The system of storing, administering and recording medicines kept in the home was looked at to establish that people are protected by robust procedures. Medication was observed to be securely stored in locked cabinets in each house and it was considered positive that staff had received training in the safe handling of medicines to further safeguard service users health and well being. Where people are prescribed medication on an “as required” basis, written protocols were in place to guide staff as to when they should be given. Two oversights with regard to recording medicines administered were observed. An Epilim tablet had not been signed for by the member of staff responsible for administration and in another case two paracetamol tablets had not been signed for by another staff member. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 18 Two staff members were able to give reasonable explanations for each oversight and it was evident that people had received their medication, however it is strongly recommended that regular medicines audits take place so that records are checked to ensure that people are receiving their medication as prescribed. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are appropriate procedures in place to listen to peoples’ concerns and complaints and safeguard them from the risk of harm. EVIDENCE: There have been no complaints made about the home since the last inspection. A log of complaints is maintained that records the nature of the complaint and the action taken in response. Information about the complaints procedure is made available to families and friends in the statement of purpose and service user guide. This is reflective of the needs of the majority of people living in the home as they have complex communication needs and are reliant on relatives to raise concerns or complaints on their behalf. One person did comment that he knew he had the right to complain and clearly understood how to do so. Staff have completed training in the protection of vulnerable adults, which should enable them to safeguard people who live in the home. The staff members spoken to by the inspector said they would always report any suspicion of abuse so that people were protected. Systems are in place to safeguard the monies of people living in the home. Staff were observed to check financial records at the shift handover. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 20 An up to date inventory of peoples’ belongings is maintained so that staff can keep track if anything goes missing and look after peoples’ possessions. Recruitment records sampled showed that a robust procedure is followed for the ongoing protection of people living in the home. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home has improved providing the people that live there with an attractive, comfortable and homely place to live. EVIDENCE: Windward Way consists of three bungalows that each have four bedrooms, a lounge and kitchen/dining room, bathrooms and toilets and a rear garden. The home is situated close to local amenities such as shops, pubs, cafes and restaurants. This is important for the people who live there as they enjoy accessing these resources. There have been improvements made to the premises since the last inspection. All lounges, kitchens, hallways and bathrooms had been redecorated. New fitted kitchens and assisted baths had been provided in each bungalow. The majority of bedrooms had been redecorated. Walkways and patio areas had Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 22 been extended to offer people who use wheelchairs more space in the garden. New equipment and furniture including washing machines and tumble dryers, sofas, televisions, carpets and beds had been provided. These improvements have enhanced the appearance of the home and made it a more pleasant environment for people to live in. The registered providers, CareTech, have responsibility for the maintenance of the premises and equipment. At this visit a shower trolley was reported to need a new part. A member of staff promptly contacted the engineer responsible for servicing the equipment, who gave advice over the telephone and agreed to fit the part the next day. Unfortunately this did not take place as there was a delay in the part being delivered. Staff made suitable arrangements to ensure that people could shower safely by utilising other equipment. The bedrooms of people being case tracked were observed. One person said that he had chosen new carpet and a flat screen television. Another person had chosen prints to decorate his bedroom wall. Bedrooms were individual in style and clearly reflective of people’s personal tastes and preferences. Attention had been made to cleanliness and hygiene in the home. There were adequate hand washing facilities, personal protective equipment for staff so that the risk of the spread of infection could be reduced and there was no evidence of poor cleansing routines. Control of Substances Hazardous to Health (COSHH) products were securely stored for the protection of people living in the home. Bathrooms within each bungalow are fitted with assisted bathing facilities that meet the needs of the people who live there. There was evidence in health and safety records that bathing aids, nurse call systems and hoists had been serviced on a regular basis to make sure they remained in good working order to reduce the risk of people’s health and safety being compromised. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 23 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a well-trained and competent team of established staff who have good understanding of their individual needs. The home operates a robust system of recruiting staff for the protection of the people who live there. EVIDENCE: From observation of staff interacting with people who live in the home it was evident that they have formed friendly and respectful relationships with them. There was a lot of joking and banter that people seemed to really enjoy. One person said, “The staff are brilliant”. Staff responded well to prompts by people who live in the home. For example, a person who clearly indicated that they wished to spend time alone was immediately supported to do so. Another person was discreetly assisted with Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 24 personal care by a staff member who noticed that a change of clothing was needed after lunch. A senior member of staff gave much consideration to arranging support for a person that needed to go to hospital following a fall and talked to others about whom the person would prefer and feel most comfortable with to reduce any anxiety for them. The home has a rolling programme for both mandatory training and that, which is relevant to the individual needs of people living in the home, such as epilepsy awareness and PEG training. Observation of staff training records and discussion with some staff members identified that training opportunities continue to be offered on a regular basis. To ensure that people are supported by a qualified staff team at least 50 of staff should achieve an NVQ in care. Information received in the Annual Quality Assurance Assessment stated that 95 of the current staff team have either achieved or are working towards this qualification. In 2007, Windward Way won an Investor In People award for high levels of supervision, training, guidance, mentorship and staff development. The award was displayed in the home. Recruitment records sampled showed that appropriate checks had been made to make sure that staff were suitably experienced and qualified to work with vulnerable adults. Criminal Records Bureau checks had been made and written references received before the employee began work so that people were protected from the risk of having unsuitable staff work in the home with them. Copies of the home’s staffing rota were observed. Three waking night staff are employed, one in each bungalow. The previous inspection identified that some people require more than one member of staff to support them during the night on occasions and that the staffing levels did not reflect their needs. Progress has been made to recruit an on call senior night support worker whose role is to provide additional cover in the home as needed. Although this team member had not yet been appointed, it was reported that the closing date for the post was imminent and that at no time had people been left unsupervised whilst night staff attended to people in other bungalows. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 25 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and management team ensured the smooth running of the home in a competent manner. Systems are in place in the home for monitoring the quality of the service offered with a view to continuous improvement. The health and safety of the people living in the home and staff was being well managed. EVIDENCE: The registered manager has been in post since 2005 and is a qualified learning disability nurse with over ten years experience in social care. The home has a Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 26 deputy manager, also a qualified learning disability nurse and three team leaders (one in each bungalow) who have registered for their Registered Manager Award. The registered manager, deputy and two of the team leaders were present during this visit and from observation of their interaction with each other and people who live in the home, clearly understood their roles and responsibilities. Quality assurance systems are in place. A representative of the registered provider (CareTech) visits the home on a regular basis to report on the standard of care provided of which reports are made available to the home. CareTech have appointed a quality officer who has begun to undertake inspections of the home to do spot checks. A CareTech area manager conducts open clinic sessions for the carers of people who live in the home every two months. A poster was displayed advertising the date of the next session, which is also sent to carers. The registered manager explained that the purpose of the clinics is to enable parents and other carers to discuss any concerns, complaints or compliments away from the home as part of an ongoing quality assurance programme. Records of meetings between the registered manager, Solihull Commissioning Department, CareTech and relatives of people who live in the home were observed. This group meet every three months to review systems and practice within the home such as the arrangements for transport, health care, activities and requirements and recommendations made by the CSCI, again as a means of auditing the quality of service provided at Windward Way. A number of checks are made by staff to make sure that peoples’ health and safety is maintained. Records showed that the fire alarm system had been regularly tested and serviced to make sure that it was working properly. Each person has a fire safety plan that describes how to assist him or her to evacuate the home safely in the event of an emergency. Staff have completed fire training to help them understand the importance of fire safety. The registered manager and another member of staff have undertaken fire safety training to a level where they have been assessed as competent to instruct other staff. Fire drills had been conducted on a regular basis to enable staff and people who live in the home to practice evacuation in the event of an emergency; each drill had been recorded. Staff have undertaken health and safety and infection control training, which should ensure a safer environment for the people who live in the home. Accident and incident recording was appropriate and notifications had been sent to the CSCI as is required by legislation. Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 27 Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 28 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 Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 29 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. Standard Regulation Requirement Timescale for action 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 YA1 Good Practice Recommendations The service user guide should be reviewed so that it contains information that is relevant to Windward Way. This will assist people to have accurate information about their home and the terms and conditions of their stay. Consideration should be given to recording activities at weekends and during the evenings so that it can be determined that people are leading a meaningful lifestyle. Health care records should be completed once treatment has been received so that it can be evidenced that people are receiving services that meet their individual needs. Medicines audits should take place so that potential errors are responded to promptly and to ensure that people receive their medication as prescribed. 2 3 4 YA13 YA19 YA20 Windward Way DS0000066539.V356576.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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. 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