Inspection on 06/09/05 for Windsor Care Home

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Windsor Care Home 01/05/07

Windsor Care Home 07/03/06

Windsor Care Home 22/02/05

Windsor Care Home 24/08/04

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

CARE HOMES FOR OLDER PEOPLE Windsor Care Home Queen Street Padiham Lancs BB12 8JW Lead Inspector Julie Playfer Announced 6 September 2005 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 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. Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Windsor Care Home Address Queen Street Padiham Lancs BB12 8JW 01282 772799 01282 441231 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Sharon Anita Han Care Home 20 Dementia over 65 years of age 20 Category(ies) of DE(E) registration, with number of places Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2005 Brief Description of the Service: Windsor Care Home is registered with the Commission for Social Care Inspection to provide personal care and accommodation for 20 Older People with Dementia. The home is a detached property set in its own grounds. There is a wellmaintained and attractive front garden, which is accessible to service users. Accommodation is provided on two floors in 8 single rooms and 6 double rooms. Access to the second floor is eased by a stair lift. Communal space is provided in two lounges, two dining rooms and one sitting/dining room. Written and pictorial signs had been placed on all the communal rooms to aid orientation around the home. The main dining room was designated as a smoking area outside meal times. The staffing levels reflected guidance previously issued by the Local Authority. Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place at The Windsor Care Home over seven and half hours on 6th September 2005. The previous inspection was carried out on 22nd February 2005. No additional visits have been made to the home since the last inspection. The purpose of the inspection was to assess important areas of life in the home and check the progress made to meet previous requirements and good practice recommendations. On the day of inspection there were 18 residents accommodated in the home. Information was obtained from care records, staff records and policies and procedures. The inspector also spoke to the residents, the staff on duty and the registered person. A partial tour of the premises was also undertaken. What the service does well: The admission procedures were thorough and the assessment of people’s needs were detailed and comprehensive. This enabled the home and prospective residents to determine whether or not the home could meet their needs. The registered person notified prospective residents in writing of the result of the assessment. Residents were cared for in a friendly and professional manner. This friendly atmosphere was also extended to visitors, who were encouraged and made to feel welcome. Wherever possible the residents’ choices in how they lived their lives were respected. Each resident had a plan of care. This document had details of what their personal and healthcare needs were and how staff were to meet these needs. Residents spoken to said, “the staff are really good with me” and “the staff are all good, you can ask them to do anything”. Varied, nutritious and well-presented meals were served. All the residents spoken to said the meals were “very good” and “there is always a good choice”. Residents were provided with clean and nicely decorated bedrooms that were well-maintained. The residents could personalise their rooms with their own ornaments and small items of furniture. The lounges and dining room were decorated in a homely and comfortable fashion, with a variety of armchairs, footstools, side tables, ornaments and wall pictures. There were good recruitment procedures to ensure that staff were suitable to be employed to work with vulnerable people. Sufficient training was given to Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 6 new employees to ensure they had the skills and competence to be able to do their work. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 - 6 The admission procedure was well managed. Residents and their representatives were provided with appropriate written information and were given assurances that their needs could be met by the home. Residents received a full assessment prior to moving into home with the result that their needs were known and met. EVIDENCE: Written information was available for residents in the form of a statement of purpose and service users guide. Both documents met regulatory requirements and were presented in a readily accessible format. Residents and their representatives were issued with a copy of service users guide prior to admission. All residents were issued with a statement of terms and conditions of residence, which included details about fees, insurance and the complaints procedure. Residents’ files contained copies of assessments completed by health and social care professionals. It was evident that it was also usual practice for the registered person to visit and assess prospective residents before offering Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 9 them a place at the home. Following the assessment prospective residents received a letter confirming that their needs could be met at the home. Residents had wide ranging needs with varying degrees of memory confusion and disorientation associated with dementia. There was evidence to indicate the resident’s needs were being met and specialist advice was sought as necessary. All residents who completed comment cards stated that they felt well cared for and that staff treated them well. The opportunity to visit the home prior to admission was part of usual practice. One resident described her visit to the home prior to moving in, which included meeting the other residents and staff and having a cup of tea. Intermediate care was not provided at Windsor Care Home. Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 -10 The care planning system fully addressed the needs of the residents and provided clear guidance to staff on how these needs were to be met. Care practice in the home took full account of the residents’ rights to privacy and dignity. EVIDENCE: From the case files seen, it was evident each resident had a plan of care, based on an assessment of needs. The plans set out in detail the action needed to be taken by staff to ensure all needs were met. It was apparent the plans had been reviewed once a month and updated in respect to any changing needs. The care plans were comprehensive and were written in a suitable format for both the staff and residents. Personal profiles had been incorporated into the care plans and provided details of past life experience. It was evident the residents’ family were fully involved in the care of their relative and participated in the care planning process. Information provided in the daily care records, care plans and the preinspection questionnaire indicated that attention was given to the residents’ healthcare needs. Risk assessments had been carried out as necessary in line with the needs of the residents. Residents were registered with a GP of their Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 11 choice and had access to chiropody, audiology and optical services. Other professionals and specialists were contacted for advice when necessary for example the Consultant Geriatrician and District Nursing Team. The home operated a monitored dosage system for the administration of medication, which was dispensed into cassette trays. Appropriate records were maintained of the receipt, administration and disposal of medication. cupboard. Arrangements were in place should a resident be prescribed controlled drugs. Since the last inspection the registered person had improved the medication procedures to ensure staff signed the medication administration record immediately after giving medication to a resident. Staff had undertaken accredited medication training. Residents spoken to felt their right to privacy was respected by the care staff and personal care was carried out with respect to their dignity. All residents were referred to by their preferred mode of address, which was documented on the care plan. Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 -15 Residents were able to make choices about their life at the home so that their lifestyle met their preferences. Residents’ social, cultural and recreational needs were met through links with their family and friends being maintained and opportunities to undertake activities both inside and outside the home. The residents enjoyed the meals offered at the home, which were varied and nutritious. EVIDENCE: The residents said the daily routine was flexible and they were able to get up and go to bed at a time of their choosing. One resident said she liked to “get up early and go to bed early” and another person said she liked to have a “lie in every morning”. The residents’ interests were documented in the care plans. A broad range of activities were planned and implemented by staff. Activities arranged in the home included arts and crafts, dominoes, music and singing, dancing, discussion and videos. In addition a professional entertainer visited the home once a month. Some residents had also enjoyed trips to Blackpool and Southport. The trips were paid for with the proceeds of the summer fayre, which was held in the garden of the home. Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 13 Resident’s meetings were held approximately every 2 – 3 months and a record was made of the discussion and any agreements made. Minutes were seen during the inspection and it was evident a range of topics were discussed. The residents were supported and encouraged to make contributions to the meetings. Visitors were welcome at the home. The residents were able to entertain their guests in any area of their choice. All relatives/visitors, who had completed a comment card expressed satisfaction with the standard of care provided by the home and all felt welcome in the home at any time. Comments received included, “I am happy with the care”, “very pleased with all the care given” and “the staff show great care and understanding”. It was part of the ethos of the home to fully support relationships between residents and their families and relatives were invited to participate in all activities and celebration days such as Christmas and birthdays. Residents were encouraged to exercise choice and control over their lives. As such residents were supported to manage their own finances. Residents were also able to bring in personal belongings and arrange their rooms how they wished. The menu was on display in the home and the choice of meals was discussed with the residents. The residents were satisfied with the quantity and variety of meals and described the food as “excellent”, “very good” and “very tasty”. Drinks and snacks were available at set times throughout the day and evening and at all other times on request. The registered person maintained a detailed record of meals served to residents. Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Systems were in place to ensure any complaints would be taken seriously and acted upon. The procedures at the home ensured residents were protected from abuse or harm. EVIDENCE: A copy of the complaints procedure was displayed behind wardrobe doors in each of the bedrooms and included in the service users guide. This gave clear directions on whom to make a complaint to and the timescales for the process. The home had a recording system in place should any complaints be made and the arrangements for dealing with complaints was included in the statement of purpose. The home had not received any complaints. There was a Whistle blowing procedure and an appropriate procedure for staff to follow should they suspect or witness an incident of abuse. These issues were discussed with staff during the Induction period. The registered person also had a copy of “No Secrets in Lancashire”. Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 - 26 Residents were happy with their accommodation at the home and lived in a safe, clean and well-maintained environment. EVIDENCE: Windsor Care Home is a detached house set in its own grounds. The home is located close to local shops and other amenities. Accommodation is provided in eight single bedrooms and six shared bedrooms. None of the bedrooms has an ensuite facility. The home also provides four bathrooms with one assisted bath and seven toilets. Communal space is provided in two lounges, two dining rooms and one sitting/dining room. It was evident from a partial tour of the home that residents had personalised their rooms with their own belongings and decoration was good throughout. The residents said their rooms were comfortable and warm. Whilst three of the shared bedrooms were below 16 sq.m, it was agreed that these rooms met the needs of the current residents. Residents had been provided with aids and adaptations to assist their independence skills, these included grab rails, handrails, and raised toilets. The Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 16 stair lift provided access to first floor accommodation. The provision of specialist equipment was determined by the needs of the residents. There was a call facility in every room. The doors to residents’ bedrooms had been fitted with appropriate locks and keys had been distributed to residents, as appropriate. Residents had access to a well maintained garden at the front of the property. The garden looked very attractive and residents enjoyed sitting on the patio area in fine weather. Radiators had been fitted with guards. To prevent scalding the baths and showers had been preset valves to guarantee water was delivered close to 43 degrees Celsius. The home was clean and odour free at the time of the inspection. A resident said, “The home is always kept very clean”. The systems for maintaining hygiene included procedures for infection control. Plastic aprons and gloves were available to staff when undertaking care duties. There was a separate laundry room, which had sufficient and appropriate equipment to meet the laundry needs of the number of residents accommodated. Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 - 30 The numbers, skill mix and competencies of staff on duty met residents’ needs. The recruitment procedures were thorough and ensured the protection of residents at the home. EVIDENCE: A recorded staff rota was completed in advance, which indicated which staff were on duty and how many hours they had worked. All staff providing personal care were aged over 18 and all staff left in charge of the building were aged over 21. The number of staff rostered for duty was sufficient for the number of residents living in the home. All new employees undertook an in house induction programme and competed a “Skills for Care” induction. The latter provided underpinning knowledge for NVQ level 2. At the time of inspection the equivalent of 80 of the care staff were trained to NVQ level 2 or above and a further 2 members of staff were enrolled on an NVQ course. Staff also attended both internal and external training courses. The registered person had delivered a training course for all the staff on caring for people with a dementia, which was certified by the Alzheimer’s Society. Since the last inspection the recruitment and selection procedure had been updated. The recruitment procedures included completion of an application form, face-to –face interview, obtaining two written references and a POVA first and CRB check. The files of two new employees were checked. These showed that the procedures had been followed and all relevant details had been obtained. Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 - 38 The staff and residents enjoyed positive relationships, which promoted an open and friendly atmosphere. Effective systems were in place to supervise the staff and maintain all mandatory records. The health, safety and welfare of residents was promoted and protected. EVIDENCE: The registered person had the overall responsibility for the management of the home and had completed NVQ 4 in Management. The registered person also has a Registered General Nurse qualification. There was evidence to indicate the registered person had undertaken periodic training to update her knowledge and skills whilst managing the home. At the time of the inspection the registered person was undertaking a course in the “Control of Infection and Contamination”. Relationships within the home were good and staff spoke about the residents with respect. The residents valued the help and support they received from the staff, who they described as “very good” and “lovely and friendly”. The staff Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 19 received supervision at least six times a year. Topics discussed during supervision were recorded on a suitable format. The leadership style was consultative and systems were in place to ensure the residents and staff fully participated in life in the home. The home achieved an Investor’s in People Award in December 2001 and this was reaccredited in 2005. The registered person had developed systems to monitor the quality of care in the home and had an annual development plan based on a systematic cycle of planning, action and review, which reflected the aims and outcomes for residents. A satisfaction survey had been carried out of residents, their relatives/representatives and visiting professional staff. However, whilst comments made about the service were positive, the results of the surveys had not been collated, published and fed back to all interested parties. Policies and procedures had been reviewed and the dates of review had been recorded. At the time of the inspection, there was no money deposited with the home by or on behalf of a resident. Records seen of payments made by residents and placing authorities in respect to fees were complete and up to date. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Documentation seen during the inspection confirmed gas and electrical systems were serviced at regular intervals. The home had a full set of health and safety policies and procedures, which were signed and dated. Regular checks were carried out on both the internal and external environment and risk assessments had been carried as appropriate. Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 2 3 3 3 3 3 Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 21 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. 1. Standard Regulation Requirement There were no requirements identified at this inspection. 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 33 Good Practice Recommendations The registered person should collate and publish the results of the annual satisfaction questionnaires in order to provide feedback for the residents and all other interested parties. Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 22 Commission for Social Care Inspection Unit 4 Petre Road Clayton-le-Moors Accrington BB5 5JB National Enquiry Line: 0845 015 0120 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 Windsor Care Home F57 F07 S9453 Windsor V244599 6.9.05 Stage 4 doc.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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