Inspection on 11/07/07 for Windmill Court

This inspection was carried out on 11th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Windmill Court 10/07/08

Windmill Court 07/12/06

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Windmill Court St Minver Wadebridge Cornwall PL27 6RD Lead Inspector Kerensa Livingstone Unannounced Inspection 11th July 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windmill Court DS0000067809.V339078.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 Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windmill Court Address St Minver Wadebridge Cornwall PL27 6RD 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) 01208 863831 01208 862890 windmillcourt@mmnh.orangehome.co.uk Thomas Henry Mallaband Limited Fiona Jane Khouri Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34), Physical disability over 65 years of age of places (34), Sensory Impairment over 65 years of age (34) Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One (1) named service user under the age of 65 years to be admitted. Date of last inspection 7th December 2006 Brief Description of the Service: Windmill Court is registered to provide personal care with nursing for up to 34 service users in the category of OP (Old age), PD (Physical disability) and SI (Sensory Impairment). The home is set within its own grounds just outside St Minver (approximately 5 miles from Wadebridge). All rooms are all single occupancy and all except one have en-suite facilities, comprising toilet and wash hand-basin. The premises offer modern accommodation and level access throughout. There are lovely rural views from the rear of the home. The grounds comprise of a variety of garden areas, including an enclosed patio with a seating area in an inner quadrant that is accessible by wheelchair, there is a large garden to the rear with paths and seating. Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection conducted over one full day by one Inspector. An Annual Quality Assurance Assessment (AQAA) was submitted prior to this inspection. The inspector had the opportunity to meet Service Users, relatives, staff, the Registered Manager and staff working within the home. Service User documentation, Policies and Procedures, record keeping and the environment were inspected. The last Key inspection was conducted on the 7th of December 2006, when there had been a change in Manager (April 06) and new owners (July 06). At this time the inspectors inspecting the home were concerned about the amount of change that the staff and service users appeared to have had to deal with over a short period of time. There were several concerns about the numbers of staff on duty and that staff were under increased pressure to provide the same service with less resources. This situation remains the same. All the service users and visitors commented on the quality of the staff and the service that they aim to provide. The current fees for the home are £620 - £650. What the service does well: What has improved since the last inspection? The complaints procedure has been updated to include the required information. The Medicines Policies and Procedures have been developed to provide clear guidance. Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 6 Food records are being kept. All documentation relating to service users is now stored securely as required from 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 Court DS0000067809.V339078.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 Court DS0000067809.V339078.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, 2, 3, & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Service Users are provided with information to enable them to make their decisions, this must include a copy of the most recent report. The Statement of Purpose is a brief document that requires some additions. Contractual information is provided to all service users. Admission to the home is based upon a comprehensive assessment undertaken by suitably qualified staff. EVIDENCE: The home has a Statement of Purpose, which was reviewed in May 2007. However individual room sizes, addresses of the Registered Persons and the fire procedure must be added. Training information must be accurate, the Statement of Purpose states that 81 of staff have achieved their National Vocational Qualification Level 2 (due to staff turnover it is 54 ) and all staff are not up to date with Food Hygiene training as stated. There is no organisational structure of the care home. The information detailed in National Minimum Standard 5.3 should be included in relation to emergency admissions Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 9 and the physical environmental standards listed in NMS 1.1 included. The Service User Guide, which is made available to prospective service users and copy is available in each room, includes information regarding funding and fees. It is recommended that service user’s views of the home, relevant qualifications/ experience of the staff and the registered persons and information about local advocacy services is included. A copy of the most recent report must be included inn the Service User’s Guide. The Statement of Purpose and a copy of the most recent report are available in the reception area of the home. The Administrator ensures that the contents are clear to new admissions and their families or representatives. The contract includes terms and conditions as required. All Service Users are provided with the contract and the Inspector observed completed documentation in home’s files. New Service Users are admitted following a full assessment incorporating the required information by a qualified nurse. The Inspector observed that families or their representatives and other professionals were involved in this thorough process. A plan of care is based upon this needs assessment. One service user informed the inspector that’ everyone made me so welcome when I moved in’. Intermediate care is not provided in this home; therefore this standard is not applicable. Windmill Court DS0000067809.V339078.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Inspector believes that the Service Users are receiving a high standard of individualised care, incorporating their health, personal and social care needs. Service Users stated that their views and wishes are taken in to consideration in all aspects of care. Medication must be administered safely. EVIDENCE: Following the pre admission assessment, a plan of care is devised. New documentation has been implemented since the last inspection. Care plans are reviewed as required, but at least on a monthly basis and include assessment tools such as Waterlow Pressure Sore risk assessment, incontinence assessment and Prideaux nutritional assessment. On inspection there seemed to be an excessive amount of documentation in service user’s files. A daily record is kept, this was observed to be mainly health and medical matters. Social activities were observed to be lacking. Care staff are compiling a ‘Getting to know you’ document, which includes preferences, likes/dislikes family history and social interests with all residents. There is evidence that service users and/or their relatives are involved in the planning of the care. It Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 11 is hoped that the existing good practice, of openness and service user led care planning, relating to recordkeeping is not lost with the new system. There is a keyworker system. All service users are registered with one of two General Practices and the staff reported good links with the Primary health care team, Physiotherapist, Macmillan nurses and the Community Mental Health team. Specialist advice is sought on an individual basis e.g. Parkinson’s Specialist nurse, Speech and language therapist. Service users are assessed to identify who is at risk of pressure sores and appropriate preventative action is taken when required. Specialist mattresses were evident in the home. The assessment process includes the use of risk assessment tools that incorporate risk management strategies, for example the Tullamore Falls Risk Scale. The documentation inspected was regularly reviewed. Continence assessments are undertaken and service users are referred to the specialist nurse when required. Nutritional screening is also undertaken. There was documentary evidence that residents had regular access to chiropody, a dentist, audiologist and an optician as required. Service Users informed the Inspector that their health needs were met, in a manner which they felt in control of and they had choices about who to see and when. All medication is administered by qualified nurses under the Nursing and Midwifery Council (NMC) guidelines. The Medicine Administration Record (MAR) sheets were signed and dated. These sheets must be checked and signed when handwritten. There is a designated medicines trolley and a suitable facility for the storage of controlled drugs. Suitable storage is provided for the medicines. There is a drugs fridge that is kept locked and fridge temperatures are monitored. The Controlled Drug (CD) cupboard was checked, storage and records were found to be correct. The administration of medicines Policies and Procedures have been updated and developed since the last inspection as recommended. One service user is self administering their medication and provided with lockable storage. Medication was observed to be left unattended on a bedside cabinet; this had been signed for on the MAR sheet suggesting the service user had taken it over twelve hours previously. Staff were observed to treat service users with respect, speaking to them in a courteous manner, using preferred names and knocking on doors of bedrooms prior to entering. Service users stated that they are shown respect and they are able to make decisions about all aspects of their care, as if they were living in their own home. Staff were observed to be very attentive and helpful to individuals that they were caring for. Service users were taken to their rooms to be seen by the GP when he visited them. Service users may receive guests in any of the communal areas or in their own rooms. Service users wear their own clothes and the laundry system appeared to support this. All rooms are for single occupancy and may have a telephone installed should a service user wish (there is also a cordless phone available so service users can receive calls in private). Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 12 Windmill Court DS0000067809.V339078.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 good. This judgement has been made using available evidence including a visit to this service. The service users enjoy the lifestyle that is offered including the social aspects of life at the home. Visitors are welcomed to the home. The meals and snacks provided are of a very high standard, and are enjoyed by the Service Users. EVIDENCE: Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 14 There is a planned activity programme led by one of the senior carers; with activities varied from ‘group’ to ‘one to one’ sessions depending on individual needs and preferences. Activity afternoons are held in the home. Recent activities were listed as general knowledge, bean bag game, a visiting entertainer singing, games, a visit out to a local Strawberry Farm and Sheepdog trials. One service user stated ‘ I love the minibus outings’. The home has a good selection of books and games available to the service users. There is a hair salon in the home; the hairdresser was visiting on the day of the unannounced inspection, visiting the home on Wednesdays and Thursday morning. Several service users visited the hairdresser on the day of the inspection, it was observed to be a relaxed and enjoyable experience for the residents. One service user informed the inspector that they were looking forward to a storytelling session that was planned, with service users recounting life stories. Communion is held fortnightly for those who wish to attend, either in the conservatory or in their room. A record is kept of some activities, however the activities coordinator acknowledged that all activities were not being recorded. Staffing shortages have impacted upon the ability of staff to engage with service users as much as they have previously done. A social history ‘Getting to know you’ is being compiled for each service user including family background, significant dates, career info, pets and personal achievements. The home has an open visiting policy, the Inspector was advised that visitors welcome at any reasonable time. Visitors were observed to be welcomed to the home on the day of the inspection, in a relaxed and friendly manner. Service users are able to maintain links with the community, visit family and friends as they wish. A Visitors Book is located in the reception area of the home. Service users are encouraged to handle their own affairs as they wish to and there is evidence of active family support. Service users stated that they could choose how to spend their time, whether to stay in their room or participate in activities, when they wished to get up and go to bed. Personal possessions are evident within service user’s accommodation. Service users are offered a varied, appealing and wholesome diet suited to individual requirements. The service users were observed to be asked on the morning on the inspection for their choice of meal for lunch and teatime. Special diets are catered for. The menu on the day of the inspection was Crispy topped liver, Toad in the hole or Cheesy egg nests, served with brussel sprouts, courgettes, carrots and leeks in sauce, creamed and new potatoes. This was followed by Stewed Plums and custard, Lemon Crunch Pie or Semolina. Lunch was observed to be a relaxed and very sociable occasion, taken by many of the service users in the pleasant dining room. Service Users choose where they wish to eat and meals maybe taken in their room, as they prefer. Staff assisted service users in a quiet and discreet fashion. Fresh fruit is made available in communal areas. Biscuits and homemade cakes are provided Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 15 with hot drinks during the day. A hot or cold alternative is offered at tea -time. Fruit, snacks and drinks are always available. The service users commented on the choice and high standard of food provided by the home, stating ‘its wonderful’ and the ‘food is lovely’. The Head Cook has obtained her Intermediate Food Hygiene Certificate; several staff are not up to date with their Food Hygiene certificates. Fourteen staff are booked onto the Foundation Food Hygiene training on the 17th July. Food records are kept. Windmill Court DS0000067809.V339078.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Relatives and service users are aware of the action to take if they are concerned about anything. The complaints procedure and Protection of Vulnerable Adults information is clear. All staff must be provided with suitable training in the Protection of Vulnerable Adults to ensure that the correct procedures are followed. EVIDENCE: The home has a comprehensive Complaints Procedure that includes timescales and stages for the process. The complaints procedure in the Service user’s guide has been updated to include the required information. Relatives and service users confirmed that they were aware of whom they could make any concerns known. The Commission for Social Care Inspection has received no formal complaints about this home. The Protection of Vulnerable Adults policy and procedure has been reviewed since the last inspection, to provide clear instruction as to the steps to be taken in the event of an allegation of abuse. Concerns about the lack of training have been identified at previous inspections. One member of staff has attended the Social Services facilitated training and ten staff have received internal training, however recent practices in this area suggest that further training is required. All staff must receive training on the Protection of Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 17 Vulnerable Adults. The Registered Manager has completed the Trainers course facilitated by the Department of Adult Social Care in January. Windmill Court DS0000067809.V339078.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, 20, 21, 22, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service Users live in a well-maintained environment that suit their individual needs. However environmental risk factors must be identified and a management plan implemented. This home is comfortable and hygienic. EVIDENCE: The location and layout of the home is suitable for its stated purpose, providing a homely environment, with wide airy corridors and level access throughout. The home and gardens are maintained to a high standard. The gardens, including a sheltered courtyard are readily available to service users and there is wheelchair access. Service user commented on the gardens and how they enjoyed sitting outside on warm day. There is a full time maintenance/gardening person, jobs are listed in the maintenance book and these are promptly dealt with. Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 19 Thirty-three rooms are single and have an en-suite facility. One room has an allocated bathroom with a toilet. There are four communal toilets, one shower room and four bathrooms. The communal space comprises of a good-sized dining room, lounge and conservatory with extensive gardens. Furnishings throughout are of a good quality and homely in nature. The communal areas appeared light and airy. There is a hair salon and designated staff accommodation and storage. The home offers level access throughout for service users; which can be easily negotiated by wheelchair. Handrails are provided throughout the corridors of the home, with grab rails provided in bathrooms and en-suites. Service users with mobility problems had been provided with a wide range of walking aids and frames to maintain independence. Equipment is sought on an individual basis, at inspection it was observed that some service users are purchasing a chair for their room. At the last inspection it was noted that most rooms have a divan bed rather than a bed that can be raised or lowered. Some have been replaced, however there are still physically dependant people being provided with divan beds. It is recommended that all rooms be provided with nursing beds as a priority (there are currently eleven). An emergency call system is provided. Service user’s rooms were pleasantly furnished and rooms were carpeted. Rooms are personalised and homely. On moving into Windmill Court Service users are able to bring their own personal possessions and small items of furniture if it complies with fire and health and safety regulations. All rooms are provided with a lockable space, but only ten out of thirty four have a lockable room. Rooms are individually and naturally ventilated, with the window openings restricted. Some rooms open out onto a quadrant garden. Radiators are uncovered, but have controlled temperatures, these are regularly checked. New boilers are being installed; the inspector was informed that the hot water is regulated at 43 degrees or below and that thermostatic valves regulate facilities that offer total immersion, such as baths and showers. However at the last inspection two bathrooms were observed to have ‘hot water’ signs where the water was regulated and the sinks in these two bathrooms was noted to have very hot water. These bathrooms remain the same, no environmental risk assessments are in place for these risks. The inspector was informed that these temperatures are checked. There is adequate natural lighting and the building is well ventilated. As recommended at the last inspection the Registered Persons should undertake a legionella risk assessment and this may involve contacting the Environmental health Officer for advice regarding legionella. There is an automated sluice, which is located away from service users facilities. There were no odours in the home on the day of the unannounced inspection. The home appeared clean and hygienic. The home employs Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 20 separate cleaning and laundry staff, who were evident during the inspection. The laundry facility appeared well organised and suitable for purpose. There is plenty of ventilation and impermeable flooring. There is one commercial washing machine with sluice facility and one industrial dryer, this is supplemented by a domestic dryer and washing machine for fragile items. Suitable hand washing facilities were available, with liquid soap and paper towels. Disposable gloves and aprons are provided for the staff. The home has an Infection control Policy. An infection control course was being held on the day of the inspection. Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 21 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. Service users’ needs are met by capable and caring staff, who are genuinely committed to working with older people. Recruitment procedures are robust and aim to protect the service user. There are concerns about reduced staff impacting upon the high standards that are aimed for. Structured skills for care induction standards are not completed within the required timescales. EVIDENCE: A qualified nurse is on duty throughout the 24- hour period, all staff are recorded on a duty rota. On the day of the Unannounced Key inspection there was a qualified nurse and seven carers in the morning, one qualified nurse and four carers in the afternoon and a nurse and two carers at night. This is for thirty-one service users. The inspector was informed that there are staff vacancies and shortages have impacted upon training and activities. No one under the age of eighteen is providing personal care to the service users. One service user informed the inspector that staff are busy in the evenings and had to wait for some considerable time before staff were able to assist them to bed, as the staff were very busy with more dependent residents. Twelve out of the twenty-two carers have achieved their National Vocational Qualification (NVQ) level 2, this equates to 54 (six carers have left since the Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 22 last inspection who had achieved their NVQ). The Registered Manager is aiming to enrol more staff on this training. The Administrator demonstrated to the Inspector that the home operates a thorough recruitment process. Staff files were well maintained. The recruitment records inspected (four) contained the required information including application Forms, contracts, Criminal Records Bureau checks and POVA first checks, training information and two written references. New staff are provided with a copy of the General Social Care Code of Practice and contracts of employment. Interview records are kept. Staff are provided with support on commencing work at the home. There is a designated staff member to support new staff. The induction programme has been updated to comply with the Skills for Care induction standards, however the inspector was informed that staff are not able to complete them within the required timescales due to the home being short staffed. In house training was due to be provided on a variety of issues recent training included diabetes supporting people with dementia, this has also been postponed due to staffing. Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 23 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, 36, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager is very experienced and capable of managing this home. There has been a significant amount of change introduced to the home since the company bought Windmill Court, this appears to have caused uncertainty and depersonalised the way the home is run. The ethos of the home appears to be changing from an integrated happy environment to a remotely managed business. Service users financial interests are safeguarded. The registered Manager does not have adequate time to undertake her duties and fulfil her responsibilities. All staff must be appropriately supervised. EVIDENCE: The Registered Manager (Ms Khouri) is a first level registered general nurse and started at the home in April 2006. Ms. Khouri has considerable experience having worked with Older People for over seventeen years, haematology and Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 24 palliative care. She has obtained the English National Board (ENB) 237 in Oncology Nursing and the Registered Manager’s Award. The Registered Manager has a job description and there are clear lines of accountability in the home. The Manager held a meeting with residents recently and minutes were taken. A representative of the company who owns Windmill Court conducts regulation 26 visits monthly; the reports resulting from these visits are forwarded to the Commission for Social Care Inspection. Over the last year staff have commented that sometimes they do not feel listened to and that new systems of work have impacted upon the level of service they are able to offer. Service users informed the inspector that they found the Manager very friendly and helpful. The home circulated a quality assurance questionnaire in April to service users and relatives. A summary was compiled, however no actions were included. This information should be included in the Service user’s Guide. There were very positive comments about staff, the only improvement noted was a new carpet for visitor’s toilet. There were comments relating to concerns about bureaucracy and remoteness of a larger organisation. No stakeholder’s information was included in this survey. Policies and Procedures are reviewed annually. The home encourages service users to control their own money where possible, or to entrust this to the next of kin or Power of Attorney. There is a Finances and Valuables Policy and Procedure, which clearly details the actions to safeguard service user’s monies. The home holds monies on behalf of a small number of service users and receipts are provided for any expenditure made on their behalf. Several personal accounts were checked and found to be correct. The records were accurate with each account being kept in separate envelopes. There is a monthly invoice system. Valuable can be safely deposited in the safe and a receipt is provided to the Service User. The staff are not currently receiving regular supervision and staff meetings have been cancelled, the inspector was informed this is due to staff shortages. All documentation relating to service users is now stored securely as required from the last inspection. At the last inspection a health and safety audit had been conducted by an external company, however no action has taken place since this. Environmental risk assessments are not being compiled, an outside agency is due to undertake the health and safety audits. There are external doors that are unlocked and the loft access in the laundry is not included in the Fire Risk assessment for the home. No legionella risk assessment is in place, a water sample has been sent off for screening. There are designated staff that take on key training roles, within the home, however staff turnover and shortages have reduced their ability to be able to meet the training needs of the staff. The Registered Manager is arranging internal infection control, food hygiene and Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 25 POVA training. Only new staff are being provided with moving and handling training. Staff must receive regular fire training four times a year for night staff and twice a year for day staff, since the last inspection fire training has been provided. The maintenance person responds promptly to day-to-day requests. The Registered Manager informed the inspector that all maintenance checks and servicing are being completed as required. Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 2 3 2 2 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 3 2 X 2 Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 27 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 OP1 Regulation 4, Sch. 1 Requirement The registered person must provide a statement of purpose including the matters listed in Schedule 1 and provide a copy to the Commission for Social Care Inspection. Previous timescales not met The service user’s guide must include a copy of the most recent report. Previous timescales not met The registered person shall make arrangements for the recording and safe administration of medicines. The registered person shall make arrangements, by training staff to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. The registered provider shall ensure that the persons employed receive training appropriate to the work they are to perform e.g. induction. Previous timescales not met 01/03/07 The registered person must DS0000067809.V339078.R01.S.doc Timescale for action 01/12/07 2. OP1 5 01/12/07 3. OP9 13(2) 01/12/07 4. OP18 13(6) 01/12/07 4. OP30 18(1c) 01/12/07 5. OP36 18(2) 01/12/07 Page 28 Windmill Court Version 5.2 6. OP38 13(4c) ensure that all staff are appropriately supervised. The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated e.g. unalarmed fire doors, hot water. Previous timescales not met 01/03/07 01/12/07 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. 3. 4. 5. 6. 7. 8, Refer to Standard OP1 OP9 OP12 OP22 OP24 OP25 OP31 OP33 Good Practice Recommendations For the service user’s guide to provide information about local advocacy services, staff training and service user’s views of the home. For handwritten Medication administration records to be checked and signed by a second nurse. For a record of activities taking place to be kept and who has participated in them. For high low beds to be provided for all accommodation where service users are likely to receive nursing care. For all service user’s rooms to be fitted with a lock suited to service users’ capabilities and accessible to staff in emergencies. The Registered Provider should contact the Environmental health Officer for advice regarding legionella and any action to be taken. For the Registered Manager to have adequate managerial time to perform her duties and roles. For stakeholder’s views to be sought as part of the quality monitoring system. Windmill Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Court DS0000067809.V339078.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!