We carried out this inspection on the 14 July 2015. The inspection was unannounced which meant the staff and registered provider did not know we would be visiting
Windsor Lodge provides care and accommodation for up to 15 people who have functional mental health needs. On the ground floor of the home there is a kitchen, dining room and small lounge. On the first floor there is a large communal lounge. Bedrooms are situated on the ground, first and second floor of the home. At the time of our inspection there were nine people living at Windsor Lodge.
The home had a registered manager in place and they have been in post since and registered with the Care Quality Commission since December 2012. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The registered manager also owned the service and worked alongside another owner.
We found that medicines were stored and administered appropriately. Risk assessments for people who self medicate needed updating.
The registered manager had knowledge of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). The registered manager understood when an application should be made, and how to submit one. At the time of our visit there was no one that was subject to a DoLS authorisation. Staff did not have a full understanding of MCA and DoLS and could do with refresher training.
Staff we spoke with understood the principles and processes of safeguarding, as well as how to raise a safeguarding alert with the local authority. Staff said they would be confident to whistle blow [raise concerns about the home, staff practices or provider] if the need ever arose.
Staff did receive relevant training although some training could do with refreshing. Such as behaviour that challenges was in in need of updating to ensure that staff remain up to date with current legislation and care practices. In house training was not recorded, for example the registered manager devised their own question and answers to test the staffs understanding of subjects such as medication and infection control, but there was nothing to evidence this had been done.
Staff had regular supervisions and appraisals to monitor their performance. However records did not detail any personal development goals for the coming year. Staff told us they felt supported by the registered manager.
Staff were observed to be caring and respected people’s privacy and dignity. People who used the service said that staff were caring and kind.
People were supported to access healthcare professionals and services.
People who used the service had freedom to come and go as they pleased and all enjoyed their hobbies such as music collections, Doctor Who and shopping.
People living at the service said they felt safe within the home and with the staff who cared for them. One relative of a person who used the service also indicated that their family member was safe.
People’s care records were person centred. Person centred planning (PCP) provides a way of helping a person plan all aspects of their life and support, focusing on what’s important to the person. The care plans were found to be detailed outlining the person’s needs and risks. Risk assessments were in place. Care plans provided evidence of access to healthcare professionals and services.
Accidents and incidents were monitored each month to see if any trends were identified. At the time of our inspection the accidents and incidents were too few to identify any trends.
Although the registered manager and owner were at the service the majority of the day, the rest of the time there was only one member of staff on duty once the domestic member of staff went home at around 2pm. The registered manager and owner said they were only a phone call away in an emergency and could be onsite in a short time if needed.
Recruitment and selection procedures were in place and appropriate checks had been undertaken before staff began work.
We saw that the service was clean and tidy and there was plenty of personal protection equipment [PPE] available.
We observed a lunchtime and teatime meal. People were provided with choice and enjoyed the food on offer.
Staff were supported by the registered manager and were able to raise any concerns with them. Lessons were learnt from incidents that occurred at the service and improvements were made if and when required. The service had a system in place for the management of complaints although had not received any.
Staff treated people with dignity and respect.
We saw safety checks and certificates that were all within the last twelve months for items that had been serviced and checked such as fire equipment and water temperature checks. There was evidence of personal emergency evacuation plans [PEEPS].
The registered provider had developed a robust quality assurance system and gathered information about the quality of their service from a variety of sources.