Inspection on 18/11/05 for Windsor Court

This inspection was carried out on 18th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Windsor Court 12/02/08

Windsor Court 31/10/07

Windsor Court 15/06/07

Windsor Court 09/01/07

Windsor Court 14/06/06

Windsor Court 26/08/05

Windsor Court 21/02/05

Windsor Court 22/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Windsor Court 34 Bodorgan Road Bournemouth Dorset BH2 6NL Lead Inspector Marjorie Richards Unannounced Inspection 18th November 2005 10:55 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 Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 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. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Windsor Court Address 34 Bodorgan Road Bournemouth Dorset BH2 6NL 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) 01202 554637 01202 297554 info@win-court.co.uk www.win-court.co.uk Lyndale Ltd Mrs Margaret Glanville Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th August 2005 Brief Description of the Service: Windsor Court is located in a quiet tree-lined road in a residential area some three quarters of a mile from Bournemouth town centre with all the facilities that can be expected in a large town, e.g. banks, post office, shops, library and places of worship. Getting to the town centre requires negotiating a steep hill as does accessing public transport although the nearest bus stop is within 200 yards of the home. Windsor Court was originally a grand gentlemens residence before being converted to a hotel and still retains many of the features and appearance of a building that was used for that purpose, although it is now registered as a care home, providing personal care for up to 42 older people. The home has a wheelchair accessible entrance area with a small lounge bar adjacent to the generous hallway. Further communal areas, comprising the spacious dining room, TV and quiet lounges are all located on the ground floor and furnished much as if the premises was still a hotel. All rooms have high ceilings and big windows. There is a good-sized, secluded and level garden at the rear of the home that is mainly laid to lawn, surrounded by mature trees and a large car parking area at the front for visitors. Windsor Court is owned by Lyndale Ltd, a family business. A five-year refurbishment plan is currently in progress, which is updating facilities and improving the standard of accommodation. Residents accommodation is located on the lower ground, ground, first and second floors of the home with access between floors via a wide staircase, passenger or stair lifts. Aids and equipment are available for residents who may have disabilities. The home is centrally heated throughout. All of the forty-three bedrooms are for single occupancy, with thirty-eight having their own en-suite WC and bathing facilities. The remaining five comprise two pairs of bedrooms, with each pair sharing the en-suite facilities and one room that has an en-suite WC and wash hand basin. Windsor Court provides 24-hour personal care, all meals, laundry and domestic services. Residents are encouraged to participate in a range of activities organised in the home. An inter-denominational religious service takes place in the home every Sunday. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5.5 hours on the 18th November 2005. The main purpose of the inspection was to check that the residents living in the home were safe and properly cared for and to check on progress with meeting requirements and a recommendation from the last inspection. An anonymous complaint, (received by CSCI on 16th November 2005) was also investigated. For further information, see Standard 16. A tour of the premises took place and records and related documentation were examined including the care records for six residents. Time was spent observing the interaction between residents and staff, as well as talking with twelve residents in private in their bedrooms. A further twenty-three residents were spoken with or observed in the communal rooms. Discussion also took place with Mr Glanville, the Senior Care Manager, Senior Assistant Manager and some of the staff on duty. What the service does well: A flexible approach is taken to the running of Windsor Court to fit in with the needs and wishes of residents. Open visiting arrangements are in place and residents are able to maintain contact with visitors, as they wish. A visitor commented, I have visited at different times of the day and have always been made to feel welcome. Flexibility of lifestyle is encouraged and residents have the opportunity to choose their own way of living within the home. Residents confirmed that their individual preferences and routines are respected. I can do what I like, when I like. I please myself when I get up or go to bed. I like to stay in my room, I prefer my own company. A system is in place for dealing with complaints and residents expressed confidence that any complaints would be listened to and dealt with appropriately. I dont think I have any complaints. I am really very contented here. If I did have something to say, I would not be afraid to say it.” If something is wrong, then the best thing is to say so. Ive done this in the past and theyve always put it right straight away. Windsor Court provides an attractive, comfortable environment for residents. A five-year refurbishment programme is taking place, but this is being carried out in such a way as to cause the minimum of disruption to residents. Residents spoke highly of the laundry service and standard of cleanliness within the home. The cleaning staff are very good here, they work very hard. Everything is always a spic and span. Someone had an accident in Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 6 the corridor the other day, but the girls cleaned it up straight away. We have a good laundry system. In some places they lose everything all the time but that doesnt happen here. All my clean laundry is returned to me very quickly. The home employs sufficient care staff, chefs, kitchen, housekeeping, domestic and maintenance staff to meet the needs of residents. Residents commented, They dont mind if you ring your bell and ask for help. They say, That is what were here for. The staff are very kind to me. I think they work hard, - I couldnt do their job. We can share a laugh and joke with the girls, (staff) they are a good crowd. Fire records show appropriate checks being carried out within the home and suitable arrangements in place for specialist servicing of the fire warning system, emergency lighting and fire fighting equipment. What has improved since the last inspection? What they could do better: The care needs of prospective residents must be fully assessed prior to admission, to ensure that only those whose needs can be met are admitted to Windsor Court. Copies of letters, confirming the care home is able to meet the prospective residents care needs, should be kept on file. All aspects of each residents health, personal and social care needs must be recorded in a care plan. At present, care plans are not being regularly reviewed and updated to reflect changing needs. There is insufficient recorded information about social care needs, making it difficult to assess if these needs are being met. Daily report notes are well detailed and document staff observations and changes in residents needs. However, little is currently Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 7 recorded to demonstrate any action taken to meet these identified needs. Information contained in the daily report notes is not always used to inform and update the care plan. The accident books show a high number of falls within the home, although many with no apparent injury recorded. There is a need for an audit to be carried out to see if any trends can be established and preventative measures put in place. Windsor Court has a comprehensive Adult Protection policy in place to ensure residents are protected from possible abuse. However, not all staff have received training in adult protection issues to ensure a proper response to any suspicion or allegation of abuse. Such training is currently being planned. The home has a detailed recruitment policy, which makes sure that appropriate checks are carried out prior to employment commencing. However, some improvement is needed in relation to Criminal Records Bureau checks, to ensure the protection of residents. Mr Glanville discussed proposed changes in the management structure of the home, to ensure the registered manager is in full time day-to-day charge of the home. It is hoped that these will be implemented early in 2006. 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 Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 8 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 Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 3 Standard 6 is not applicable at Windsor Court. Without consistently detailed pre-admission assessments and confirmation in writing, there is insufficient assurance that prospective residents know the home they are moving into is able to meet their needs. EVIDENCE: Individual care records are kept for each resident and six of these were examined, including those of recently admitted residents. The records demonstrate that, prior to moving to Windsor Court, pre-admission assessments have taken place to determine whether the home could meet the prospective residents care needs. However, the form used for this purpose is not always completed consistently. On some forms a detailed assessment has taken place, but on others the information is more limited. The care needs of prospective residents must be fully assessed, to ensure that only those whose needs can be met are admitted to Windsor Court. Mr Glanville provided a sample letter and gave an assurance that, following the assessment, a letter of confirmation is written to the prospective resident so that they may feel fully assured their care needs will be met. It is Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 10 recommended that a copy of such letters be retained in the individual residents file. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 7 (and 9) Windsor Court has a care planning system in place to provide staff with the information they require to meet the health and personal care needs of residents. However, care plans are not being reviewed frequently enough, to ensure they are always updated to reflect changing needs and current objectives, leaving residents potentially vulnerable. There is insufficient recorded information about residents social care needs, so it is difficult to assess if these needs are being met. Records indicate that residents receive their medicines as prescribed. Procedures for administering medicines need reviewing and some improvement is needed in updating the dose directions for medicines clearly and ensuring that all medicines can be accounted for to protect service users. EVIDENCE: Care plans are intended to provide staff with the information they require to meet the health, personal and social care needs of residents. Each resident has his or her own individual plan of care, which should be reviewed at least monthly, (more often if required), to reflect changing needs. Following Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 12 examination of six care plans it could not be evidenced that regular reviews are always taking place. Observation throughout the inspection and discussions with residents and staff confirmed that further updating of care plans is required so that staff have the information they need to ensure all care needs are fully met. The daily reports are well detailed and document staff observations and changes in residents needs. However, little is recorded to demonstrate that action has been taken to meet these identified needs. Information contained in daily reports is not always used to inform the care plan. This Standard seeks the involvement of residents in the development of care plans and suggests that plans be recorded in a style accessible to residents and agreed and signed by them (or their representative) wherever possible. The Senior Care Manager says she is working towards involving residents in care planning and this was evidenced in one care plan seen, which had been signed by the resident. At present, only limited information about social care needs is recorded and included in the Care Plan. The Senior Assistant Manager is currently gathering further information about each residents social needs and expectations, to look at the best ways of meeting these. (See also Standard 12.) Falls risk assessments are in place, but examination of the accident books shows a high number of falls still occurring, although many with no apparent injury recorded. It is required that an audit be carried out over a 12 month period, to include the cause of the fall, (if known) the time of fall and location, as well as the type of injury sustained to see if any trends can be established and preventative measures taken. A copy of this audit should be forwarded to the Commission. The home should be aware of the need to report any serious injuries involving fractures not only to the Commission, (Care Homes Regulations, regulation 37) but also under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR). The Commission for Social Care Inspection Pharmacist Inspector carried out an inspection of the home in May 2005. A further follow up visit in August found some progress had been made in the arrangements for the recording and handling of medicines in the home, but further work was needed particularly in the procedures for administering medicines. The Senior Care Manager reports that the three requirements and two of the three recommendations have now been met. These were not checked during this inspection and will be followed up by the Pharmacist Inspector. The remaining recommendation regarding the drug cupboard is repeated at the end of this report. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 Plans are in hand to improve the range of activities available to residents, to satisfy their needs and wishes. Residents are encouraged to maintain contact with family and friends and the wider community. Residents are able to choose their own lifestyle within the home and their individual preferences and routines are respected. EVIDENCE: A flexible approach is taken to the running of Windsor Court to fit in with residents needs and wishes. A number of activities are available within the home. Residents commented, I like to have a game of Scrabble. We have an exercise class here every week, which is a bit of fun. I enjoy reading and the library comes here regularly. We have a Church service here every Sunday, which I like.” At the last inspection, some residents commented that they would like to see a wider range of activities available. The Senior Assistant Manager is currently seeking the views of residents regarding the changes they would like to see and is purchasing some new games and reminiscence materials. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 14 She also intends to start collating further information about each residents background, social history, previous hobbies and interests etc. This will help to ensure that the activities on offer at Windsor Court will be meeting the individual needs, preferences and expectations of residents. It is hoped to see the benefit of these planned improvements at the next inspection. Mr Glanville says visitors are made welcome at any reasonable time. Visitors and residents confirmed this during the inspection. A visitor commented, I have visited at different times of the day and have always been made to feel welcome. Residents records and the visitors book demonstrate contact with family and friends as well as visits by professionals. A few residents are able to go out of the home alone and others with their families/friends or with staff. A telephone is available for any residents wishing to make phone calls. Twelve residents have their own telephones installed in their bedrooms and several also have mobile phones so they are easily able to keep in touch with relatives and the wider community. Residents are encouraged to choose their own lifestyle within the home and make choices wherever possible. These include choosing when to get up or go to bed, what to wear, how to spend their time, what to eat or drink and also freedom to come and go as they please. They are able to bring their own possessions into the home to personalise their bedrooms. Residents confirmed that their individual preferences and routines are respected. I can do what I like, when I like. I please myself when I get up or go to bed. I like to stay in my room, I prefer my own company. The home has a policy and procedure in place regarding the residents right to access their records if they wish. Personal records were seen to be kept securely, with due regard for confidentiality. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 16, 17 and 18 A system is in place for dealing with any complaints. Residents are confident complaints would be listened to and dealt with appropriately. Residents have their legal rights protected and are assisted in exercising their rights. The home has a comprehensive Adult Protection policy in place to ensure residents are protected from possible abuse. However, not all staff have received training in Adult Protection issues to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a complaints policy and procedure that is included in the Service User Guide provided to all residents. A copy of the complaints policy is also available to all visitors in the entrance hall. The Senior Care Manager confirmed that no complaints have been received by the home since the last inspection. Contact with residents and visitors demonstrated they would feel able to voice a complaint and feel their concerns would be taken seriously, and acted upon. Comments included: I have never had to make a complaint. If I was worried about something I suppose I would tell the staff or the person in charge.” I have no complaints at all, I am very settled here.” I dont think I have any complaints. I am really very contented here. If I did have something to say, I would not be afraid to say it.” If something is wrong, then the best thing is to say so. Ive Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 16 done this in the past and theyve always put it right straight away. An anonymous complaint was received by the Commission for Social Care Inspection on 16/11/05 and investigated during this inspection. The complaint covered a number of issues and these are listed briefly below, along with details of outcomes. MANAGEMENT (See Standards 31, 32 and 33.) Poor management, many staff leaving as a result. Unsubstantiated. Management team not approachable. Unsubstantiated Management not always available. Partly substantiated. See requirements EMPLOYMENT (See Standard 29) Staff have not had Criminal Records Bureau checks before commencing employment and work permits are out of date. Partly substantiated re CRB checks. See requirements. Standards of care gone down because they just employ anyone. Unsubstantiated. STAFFING/CARE (See Standards 27, 28 and 30) Insufficient staff on duty. Staff under pressure and stressed out as a result, leading to poor care standards. Residents not washed, shabbily dressed. Unsubstantiated. Residents are very insecure with so many foreign people working in the home. Some care staff have a poor grasp of the English language. Unsubstantiated. Racial discrimination. Unsubstantiated. Staff training, especially fire training. Unsubstantiated. MEDICATION/HEALTH (See Standard 9) Concerns about medication administration. For follow-up by Pharmacist Inspector. ENVIRONMENT (See Standard 26) Home smells of urine and faeces as soon as you walk through the main doors. Unsubstantiated. Further information regarding these issues can be seen by referring to the Standards mentioned above, in the body of this report. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 17 Mr Glanville says the home undertakes to assist residents in utilising their rights as fully as possible. All residents are placed on the electoral roll when admitted to Windsor Court. During local and national elections, opportunities are made available to all residents to vote if they wish, either in person, by post or by proxy. Transport to the polling station is provided if necessary. A number of residents chose to vote by post at the General Election in May 2005. The home provides information about advocacy services, where residents lack capacity or require independent support or advice. The home has an Adult Protection policy in place to protect service users from possible abuse. This makes reference to the Department of Health No Secrets document, which is also available to staff. However, at the last inspection a requirement was made for all staff to receive training in Adult Protection issues, to ensure a proper response to any suspicion of abuse. Mr Glanville says such training is currently being arranged for early in 2006. This requirement is therefore carried forward at the end of this report. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23, 24 and 26 Windsor Court provides an attractive, comfortable and well-maintained environment for residents. Considerable investment is planned for the future improvement and refurbishment of the home. Residents have access to a choice of attractive communal areas, including gardens. The home provides sufficient bathrooms and WCs to meet the needs of residents. Bedrooms are comfortably furnished and individually personalised to suit the needs of their occupants. Windsor Court is clean with no unpleasant smells, making daily life more pleasant for all in the home. EVIDENCE: The programme of refurbishment is continuing, with several more bedrooms undergoing redecoration, replacement of items of furniture and the fitting of some new carpets. Inspection of the premises confirms that routine maintenance is being carried out. Detailed maintenance records are kept and Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 19 maintenance staff ensure prompt attention to defects etc, whenever necessary. For additional security, all exit doors from the building have had alarms fitted, so that staff may be alerted if the doors are opened. Records demonstrate regular servicing of equipment, such as hoists, passenger lift and stairlifts to help ensure a safe environment for residents. Windsor Court has a choice of communal areas available to residents. There is a large, spacious dining room, a TV lounge, a quiet lounge and a small bar lounge. All of the communal rooms were seen to be well used by residents throughout the inspection. There is also a large garden to the rear of the home with garden furniture available. Access to the garden will be improved when the refurbishment is completed. Windsor Court has sufficient baths, WCs and washing facilities to meet the needs of residents. There are no purpose built assisted baths in the home but a number of portable hydraulic bath seats are available to provide assistance for those who need help getting in and out of the bath. The provision of purpose built assisted baths and showers forms part of the 5-year plan of refurbishment and improvement of the home. It is anticipated that these new bathrooms will be in place during 2006. All except four bedrooms have en-suite WC’s, wash hand basins and baths. These four rooms are arranged in pairs, with each pair sharing a WC and bath. Residents spoken with confirmed that their bedrooms suited their needs. Windsor Court is registered to accommodate up to 43 residents in single bedrooms. All rooms measure at least 10 square metres in size, although some are considerably larger than this. A tour of the building confirmed that residents bedrooms are comfortably furnished and personalised to varying degrees. Bedrooms are also gradually being refurbished as part of the 5-year plan. Residents commented, I love my room. I enjoy spending time here.” I have my own things around me, which makes it more like home I have no complaints about my room, I have everything I want.” The laundry is sited on the lower ground floor and a member of staff is dedicated to managing the personal laundry of service users. The laundry is equipped with washing machines that have sluice programmes and are able to operate at 65ºC for a minimum of ten minutes. Suitable facilities and procedures are in place in respect of the disposal of clinical waste. Staff confirm that protective clothing is readily available, e.g. disposable gloves and aprons. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 20 In discussion with residents about cleanliness in the home and the laundering of their personal clothing, all felt this was managed very well. Residents commented, I have been in some places that are dirty and a bit smelly, but it is much better here. The cleaning staff are very good here, they work very hard. Everything is always a spic and span. Someone had an accident in the corridor the other day, but the girls cleaned it up straight away. We have a good laundry system. In some places they lose everything all the time but that doesnt happen here. All my clean laundry is returned to me very quickly. On the day of inspection the premises were clean and free from offensive odours throughout. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The numbers and skill mix of staff are sufficient to meet the current needs of residents. Windsor Court has achieved the minimum ratio of 50 trained members of care staff at NVQ level 2, to help ensure residents are in safe hands. The home has a detailed recruitment policy, which makes sure that appropriate checks are carried out prior to employment commencing, for the protection of residents. However, some improvement is needed in relation to Criminal Record Bureau checks. The home acknowledges the importance of staff training and is taking steps to ensure that staff are well trained and competent to do their jobs. EVIDENCE: Examination of the staff rota, discussion with residents, Mr Glanville, managers and staff, as well as observation throughout the inspection, demonstrated a sufficient number and skill mix of staff to meet the current needs of residents. However, if the number of high/medium dependency residents increases, staffing levels may need to be reviewed. On the day of inspection, three senior care assistants and four care assistants were on duty in the morning and one senior care assistant and four care staff during the afternoon and evening. From 7.45 p.m. until 8 a.m. there are three Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 22 wakeful night care staff on duty, including one senior care assistant. In addition, at least one member of the management team is on duty each day and available on call at all other times. The home also employs chefs and kitchen staff, housekeeping/domestic and maintenance staff. In general, residents and staff feel that the staffing levels are satisfactory. Residents commented, There are enough staff. Someone always comes quickly if you ring your bell. They dont mind if you ring your bell and ask for help. They say, That is what were here for. The staff are very kind to me. I think they work hard, - I couldnt do their job. Sometimes you dont see any staff around, but they come quickly enough if you need help. I would like it if they had more time for a chat, but I know they have their work to do. Staff commented, I get on well with the others, they are a really nice crowd of people. We work hard, but I enjoy it. We have enough staff on duty most of the time. It sometimes gets busy but we cope. On the whole, we cope very well. In view of the anonymous complaint, (see Standard 16) considerable time was spent observing relationships between managers, staff and residents, both directly and indirectly, throughout the course of the inspection. They were always professional. One resident was overheard apologising to a member of staff, I am sorry, I am so very slow. The carer immediately responded, Take your time. There is no need to worry, take as long as you need. (The carer was not aware of the Inspectors presence.) It was also good to hear friendly banter between individual residents and staff. Residents commented, We can share a laugh and joke with the girls, (staff) they are a good crowd. Nothing is too much trouble. We have some very nice girls working here. The Senior Care Manager spoke confidently about the recruitment process at Windsor Court. The staff team includes individuals from countries other than the United Kingdom and the home has a written policy about equal opportunities. In addition, all staff are given a copy of the General Social Care Council Code of Practice for Social Care Workers. This states that staff should, work openly and cooperatively with colleagues, treating them with respect and promote equal opportunities for service users and carers, respecting diversity and different cultures and values. Staff felt they worked well together. The Senior Care Manager says she ensures that all staff working directly with residents have a good grasp of the English language. Two staff with poor English language skills are employed but they no not have contact with residents. A member of staff commented, We make a good team here. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 23 The home has a stable workforce. Since August 2003, records show that eight staff have left, some because their visas, giving them the right to work in the UK, had expired. Six new staff have been employed since August 2003. Documentation demonstrates that the home is intending to operate a thorough recruitment procedure to ensure the protection of residents. The four staff files examined showed that the necessary documentation, e.g., Criminal Records Bureau (CRB) disclosures, references etc, had been obtained. Where staff are coming from abroad, the files demonstrate that appropriate information is gathered about the right to work in the UK and any possible restrictions on that work. However, one member of staff had commenced work prior to receipt of a CRB disclosure or POVA (Protection of Vulnerable Adults) check being carried out. This member of staff did have a recent enhanced CRB disclosure from her previous employment and was being supervised in her work at Windsor Court until the arrival of the new CRB disclosure. However, a POVAfirst check had not been requested. At present, Windsor Court employs 24 care staff. Of these, 14 have achieved NVQ level 2 or level 3 training, which means the home exceeds the recommended minimum ratio of 50 trained members of care staff at NVQ level 2, to ensure residents are in safe hands. In addition, a further three members of staff are currently undertaking NVQ level 3 training. Discussion with management and staff evidenced that there is a commitment to staff training and development. Training is taken seriously, as a means of improving the standard of care provided and ensuring residents safety. All new staff receive induction and foundation training. The Senior Care Manager is aware of the recently introduced Skills for Care Common Induction Standards and will be developing these at Windsor Court, in conjunction with the homes own induction and foundation training programme. An individual training record is in place for each member of staff. Copies of all training certificates are being retained to provide evidence that staff receive a minimum of three paid days training per year. Certificates were viewed in relation to those staff receiving training in dementia awareness, first aid and infection control in 2005. The Senior Care Manager says she ensures that staff dealing with food have training in basic food hygiene and all staff have moving and handling training. Further training is currently being planned early in the New Year. It is recommended that a training audit be carried out, to demonstrate that all staff have received the training they need to have the knowledge and skills necessary to carry out their work. (With particular reference to moving and handling, Adult Protection, first aid and infection control). The home holds an Investors in People award. This is a national award that requires an organisation to demonstrate that staff are trained and competent to ensure that they can deliver the organisations aims and objectives. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Windsor Court has an experienced management team in place. However, the registered manager is spending insufficient time in the home. Windsor Court regularly reviews its performance and actively seeks the views of residents, staff and relatives to ensure the home is run in the best interests of residents. Residents have their financial interests safeguarded. A formal staff supervision system is now in place, but this is not always being implemented at the recommended intervals. The home endeavours to promote the health and safety of residents. However, unguarded radiators and pipework may potentially pose risks to their safety. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 25 EVIDENCE: Mrs Margaret Glanville, the registered manager, was not on duty on the day of inspection. The Inspector was grateful for the time and assistance given by the Senior Care Manager, the Senior Assistant Manager and also Mr James Glanville, on behalf of Lyndale Ltd. All five members of the management team have experience in caring for older persons. In addition, two have nursing qualifications, one has the National Vocational Qualification (NVQ) level 4 in care and two have the Registered Managers Award. However, Mrs Glanville has not yet undertaken the NVQ level 4 in management and care. The staffing roster also shows a reduced presence by the registered manager, although other members of the management team are available in the home. The registered manager has responsibility for the day-to-day running of the home and the hours worked must reflect this. Mr Glanville discussed proposed changes in the management structure of the home and it is hoped that these will be implemented early in 2006. Mr Glanville says he ensures an open door policy is in place, allowing anyone to come and see him or other members of the management team at any time. This was seen in action throughout the day. Staff felt the management team to be supportive, You can always go and ask if you need to know something. Residents also commented, I think this place is very well run. Everything always seemed to go very smoothly. I see the owners about the place. It is nice to have a chat with them sometimes. They come and sit in the lounge sometimes and chat to us, tell us whats going on. Managers and staff frequently spend time talking with residents informally to obtain their views. Occasional formal meetings for residents are held, but it is planned to introduce regular quarterly meetings during 2006, which will be minuted. Mr Glanville is also hoping to produce a Windsor Court newsletter in the near future, to keep everyone in touch with what is happening in the home. Some residents said they were consulted about what went on in the home, including plans for refurbishment and activities/social events, others could not remember this. Residents and relatives complete quality Assurance questionnaires annually. Comments or suggestions are discussed and a plan drawn up to action these wherever possible e.g. the provision of more entertainment and activities. A further questionnaire is being planned for other visitors to Windsor Court. The majority of service users either manage their own financial affairs or have relatives and/or representatives to assist them. The home holds some monies for eight residents. A record is maintained showing all deposits and withdrawals and entries are signed by the resident. Receipts are retained, as necessary. All monies and related records are held securely. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 26 Care staff should receive formal supervision at least six times a year, as a means of ensuring good practice, emphasising the philosophy of care within the home and looking at individual career development needs etc. Staff supervision is taking place but care needs to be taken to ensure this takes place six times a year and is fully documented. Monthly staff meetings also provide opportunities for staff to express their views and ideas. The minutes are displayed on the staff notice board. Staff appraisals are carried out annually to assess any training needs, ensure staff are fulfilling their role satisfactorily and are meeting the needs of residents. From touring the premises, looking at records and discussions with staff and residents, it is evident that measures are in place to promote the health and safety of residents, e.g. equipment, such as the lift, portable electrical appliances etc are regularly serviced and maintained. All substances that could be potentially hazardous to health are handled and stored safely. Detailed maintenance records are kept and maintenance staff ensure prompt attention to defects etc, whenever necessary. All radiators in public areas are guarded to ensure residents safety. Mr Glanville says it is intended to fit guards to all radiators as part of the planned refurbishment. It is recommended that this be made an early priority, to ensure resident safety. During the inspection, all alarm call bells were answered promptly and efficiently by staff. Times taken to answer call bells are monitored in the office, where all response times are logged. This record was checked during the inspection as the system was demonstrated. During this demonstration, the response times recorded sometimes showed as much longer than actually the case. It is recommended that the system be checked to ensure accuracy of recording. Fire records show appropriate checks being carried out within the home. Suitable arrangements are in place for specialist servicing of the fire warning system, emergency lighting and fire fighting equipment. At the last inspection, two Immediate Requirement Notices were issued in respect of staff fire training and fire drills not taking place at appropriate intervals. The responsibility for all matters to do with fire safety has now been delegated to the Senior Assistant Manager. Since the last inspection, two fire drills have taken place to ensure that staff (and, as far as possible, residents) are fully aware of what to do in the event of fire. The fire notices have been updated (and now also include a night-time procedure). The Senior Assistant Manager is in charge of staff fire training and is also planning to include a session by an external provider to ensure staff are fully conversant with what is required. Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 27 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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 X 3 X 3 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 28 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 OP3 Regulation 14(1) Requirement The registered person must ensure that new residents are admitted only on the basis of a full assessment. Pre-admission assessments undertaken by the home must be fully documented and contain the information detailed in this Standard. All aspects of each resident s health, personal and social care needs must be recorded and regularly reviewed, at least monthly. Care plans are to be agreed and signed by the resident or their representative wherever possible. It is a requirement that an audit of the accident records be carried out over the last 12month period, with particular reference to falls. This should include the cause of the fall, (if known) the time of the fall and location, as well as the type of injury sustained, to see if any trends can be established. A copy of this audit should be forwarded to the Commission. Timescale for action 28/02/06 2 OP7 14 and 15 28/02/06 3 OP7 13(4)(c) 28/02/06 Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 29 4 OP18 13(6) 5 OP29 19(1) 6 OP31 8 and 9 7 OP31 9(2)(b)(i) 8 OP36 18(2) It is required that all staff receive suitable training in Adult Protection issues, to ensure a proper response to any suspicion or allegation of abuse. The registered person must not employ staff to work with residents until satisfactory checks have been carried out. It is a requirement that arrangements are made to ensure the registered manager is in full-time day-to-day charge of the care home. It is a requirement that the registered manager has the qualifications, skills and experience necessary for managing the care home. The registered manager should obtain an NVQ level 4 in management and care, or equivalent. The registered person must ensure that staff are appropriately supervised. Formal supervision should take place at least six times a year. 28/02/06 28/02/06 28/02/06 31/12/06 28/02/06 Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 30 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 OP3 Good Practice Recommendations It is recommended that, following the pre-admission assessment, a copy of the letter confirming the care home is able to meet the prospective residents care needs be retained in the residents file. It is recommended that the home should have a cupboard that complies with the Misuse of Drugs (Safe Custody) regulations 1973 for storing Controlled Drugs (CDs). It is recommended that, where possible, further information about each residents background, social history, previous hobbies and interests etc. is recorded, to ensure that the activities on offer at Windsor Court will be meeting the individual needs, preferences and expectations of residents. It is recommended that an audit of staff training be carried out to ensure all staff are receiving the training they need. It is recommended that, as refurbishment takes place, the guarding of radiators be made an early priority, to ensure resident safety. It is recommended that the system for logging response times to alarm call bells be checked to ensure accuracy of recording. 2 3 OP9 OP12 4 5 6 OP30 OP38 OP38 Windsor Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 31 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Court DS0000032192.V267316.R01.S.doc Version 5.0 Page 32 - 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. 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