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Inspection carried out on 25 July 2017

During a routine inspection

The inspection took place on 25 July 2017 and was unannounced. This meant the provider and staff did not know we were going to visit.

We last inspected this service in July 2015, when it was found to be complying with all the regulations and we rated the service as ‘Good.’.

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 who did not require assistance with their personal care. We discussed with the provider and manager whether they needed to maintain the registration of the service, as personal care was not being provided. We heard how staff occasionally needed to support two people with their personal care needs and envisaged that in the future this may become a more frequent occurrence.

The service had a registered manager who was also one of the provider’s directors. They had been the registered manager of the service since January 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.

People told us they were happy being supported by the service and felt the staff were friendly and helpful. People were extremely independent and organised their day. However, any risks they might encounter were assessed by the staff and actions were taken to minimise any harm to them. Staff had been trained in safeguarding issues and knew how to recognise and report any abuse.

People’s medicines were managed safely.

There were enough staff to meet people’s needs. Any new staff were appropriately vetted to make sure they were suitable and had the skills to work at the service. The staff team had been in post since the last inspection and had a good knowledge of people’s needs and preferences. They were given support by means of regular training, supervision and appraisal.

All of the people were able to make informed decisions about the support they received and how they lived their lives. Some restrictions were in place, such as people needing to be let back into the service after they had been out and informing staff when they intended to go out. But we found that people agreed with the restrictions because it prevented unwanted guests entering the home and meant in the event of a fire staff would not be looking for them if they were out.

Staff made the meals but if people wanted they could make their own. Each person’s dietary needs were fully understood and people told us staff encouraged them to eat a healthy diet.

People were supported, where appropriate to manage their health needs. Staff responded promptly to any changes in a person’s health or general demeanour.

People told us staff treated them with respect and protected their privacy and dignity at all times.

People were encouraged to be as independent as possible.

Support plans were in place to meet people’s assessed needs. These plans incorporated people’s wishes and preferences about how their support was to be given. We discussed how these could be enhanced by making them more focused on supporting people’s rehabilitation.

People enjoyed active social lives and used the full range of community resources.

People told us they had no complaints about their care, but would feel able to share any concerns they had with the manager.

Systems were in place for auditing the quality of the service and for making improvements.

Inspection carried out on 14 July 2015

During a routine inspection

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.

Inspection carried out on 7 October 2013

During a routine inspection

We spoke with five people who used the service, the manager a support worker and a volunteer.

People who used the service expressed satisfaction with the care and service that they received. One person we spoke to said the “staff do a good job” and another said that “staff will sort out any concerns which I have.”

Two people we spoke with said that “I have made friends here” and “I am doing well here.” They said that they can talk with the staff and one said “they are all nice, I can have a laugh with them”

We found that before people received any care or treatment they were asked for their consent and the provider acted in accordance with their wishes.

There was a friendly and relaxed atmosphere between people and staff working at the home. We observed staff interacting well with people and supporting them which had a positive impact on their wellbeing. People's views were taken into account in the assessment and care planning process.

We saw that the home was clean and there were systems in place for on-going cleaning and infection control.

We saw the service had appropriate equipment and regular checks and servicing of equipment was undertaken to ensure that it was safe.

We saw the home had a complaints procedure in place and this was accessible to people.

Inspection carried out on 3 May 2012

During an inspection to make sure that the improvements required had been made

During the inspection we spoke with five people who used the service. People spoken with were very happy with the care and support that they received. Comments made included:

"Brilliant I want to stop here for the rest of my life."

"They have turned me around since I came here. I am much better."

"Staff are very kind and polite."

"I like to be involved and help. I do the hoovering and I like to do the shopping."

"It's nice, it's great."

"I have got a bus pass. I can come and go as I want. I go to bed at about 12 midnight and get up at about 11am. I have negotiated to have my breakfast at 11am."

"I order my own prescription from my doctor and pick up the prescription. I take my own tablets. I keep them in a locked drawer."

During the inspection we sat in the dining room of people who used the service. We saw that staff treated people with respect and dignity. We observed lunch time. People were given a choice of what they wanted to eat. Lunch time was relaxed with people enjoying the food that was provided. People who used the service interacted well with each other. The environment was homely, conversation flowed and the atmosphere was lively. During the day people could come and go as they pleased. One person got involved with tidying up. One person went to play football whilst another got the bus to Hartlepool. People made cups of tea and coffee when they wanted.

Inspection carried out on 3 May 2012

During an inspection to make sure that the improvements required had been made

During the inspection we spoke with five people who used the service. People spoken with were very happy with the care and support that they received. Comments made included:

"Brilliant I want to stop here for the rest of my life."

"They have turned me around since I came here. I am much better."

"Staff are very kind and polite."

"I like to be involved and help. I do the hoovering and I like to do the shopping."

"It's nice, it's great."

"I have got a bus pass. I can come and go as I want. I go to bed at about 12 midnight and get up at about 11am. I have negotiated to have my breakfast at 11am."

"I order my own prescription from my doctor and pick up the prescription. I take my own tablets. I keep them in a locked drawer."

During the inspection we sat in the dining room of people who used the service. We saw that staff treated people with respect and dignity. We observed lunchtime. People were given a choice of what they wanted to eat. Lunch time was relaxed with people enjoying the food that was provided. People who used the service interacted well with each other. The environment was homely, conversation flowed and the atmosphere was lively. During the day people could come and go as they pleased. One person got involved with tidying up. One person went to play football whilst another got the bus to Hartlepool. People made cups of tea and coffee when they wanted.

Inspection carried out on 28 November 2011

During a routine inspection

During our visit we spoke with three people who used the service. People who used the service expressed satisfaction with the care and service that they received.

One person said, "It's the finest place. They are all very kind." Another person said, "I have improved since coming here. The staff are good." Another person said, "Staff are approachable and there when you need them."