Inspection on 19/02/08 for Windsor Court

This inspection was carried out on 19th February 2008.

CSCI found this care home to be providing an Excellent service.

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 Court 23/02/10

Windsor Court 09/02/09

Windsor Court 19/02/07

Windsor Court 24/05/06

Windsor Court 07/12/05

Windsor Court 06/06/05

Windsor Court 02/11/04

Windsor Court 10/05/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Windsor Court The Avenue Wallsend Tyne & Wear NE28 6SD Lead Inspector Aileen Beatty Key Unannounced Inspection 19th February 2008 09:30 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 DS0000028829.V356916.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. Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windsor Court Address The Avenue Wallsend Tyne & Wear NE28 6SD 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) 0191 263 5060 0191 263 3472 windsor@ladhar.co.uk Mr Baldev Singh Ladhar Linda Gonzalez Rodriguez Care Home 45 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (35), Learning disability (3), Mental disorder, of places excluding learning disability or dementia (1), Mental Disorder, excluding learning disability or dementia - over 65 years of age (4) Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2 of the LD beds are currently occupied by named residents. If any of these residents vacate the beds, the Commission for Social Care Inspection must be notified, when action will be taken to revert those places to the category DE(E). 1 MD bed is currently occupied by a named resident. Once this resident leaves the home the Commission for Social Care Inspection must be notified when action will be taken to revert that place to the category DE(E). One short stay respite bed can be used for one specified resident as agreed category LD, otherwise it is category DE(E). 1 DE bed is currently occupied by a named resident. Once this resident leaves the home the Commission for Social Care Inspection must be notified when action will be taken to revert that place to the category DE(E). 19th February 2007 2. 3. 4. Date of last inspection Brief Description of the Service: Windsor Court is a purpose built three storey Care Home providing both Nursing and Residential care for up to 45 service users. Categories of care are Dementia, Learning Disabilities and Mental Disorder. The home provides care for service users above and below 65 years of age. The home is situated in The Avenue, Wallsend, close to the High Street, giving ease of access to shops, stores, restaurants and other public amenities. The fees range from £360 per week to £370. A service user guide and Statement of purpose for the home are available which provide information for potential residents and their families. A copy of the most recent inspection report is also available. Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent quality outcomes. Before the visit: We looked at: • Information we have received since the last visit on 4th December 2006. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 19th February and 4th March. During the visit we: • Talked with people who use the service, relatives, staff, the manager & visitors. • Looked at information about the people who use the service & how well their needs are met, • Looked at other records which must be kept, • Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, • Looked around the building/parts of the building to make sure it was clean, safe & comfortable. We told the manager what we found. What the service does well: Windsor court provides a homely environment where residents feel comfortable and safe. There are lovely gardens for residents to explore and other areas of interest in the home. The home is well led by the management team and staff are keen to develop the service further. Meals are home cooked and of a very good standard. Regular choices are offered. Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Windsor Court DS0000028829.V356916.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 Windsor Court DS0000028829.V356916.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 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is good information available to enable service users to make choices about where they live and detailed assessments are carried out. EVIDENCE: Detailed packs of information are provided to all residents including managers contact details and out of hours mobile telephone number. Residents are also provided with terms and conditions, and are encouraged to visit the home. A number of pre visits might take place before someone decides they want to move permanently into the home, including shorter or overnight visits. Care managers provide comprehensive assessment information before anyone moves into the home, and staff in the home also carry out a pre admission assessment to ensure they can meet the needs of the resident. Those read during the inspection were detailed and contain useful information to enable Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 Page 9 staff to write initial care plans to advise staff how to look after the person until more thorough information is gathered over a longer period. Windsor Court DS0000028829.V356916.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are of a high standard and information is detailed. EVIDENCE: The care plans of four residents were read during the inspection. The format of care files is very good and they are well organised. Assessments are carried out relating to the physical, psychological, social and emotional needs of residents and this information is used to inform care plans. This information is reviewed on a regular basis. “This is your life” documentation relates to the past life history of people living in the home. They contain detailed and fascinating information about individuals that can be used to help the residents to settle into the home and prompt conversations and activities. The information is also useful for adding to care plans to help staff get to know people better and have a sense of what they were like when they were younger or before they became ill. Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 Page 11 Monthly nutrition meetings are held to discuss every residents weight, nutritional needs and preferences. Staff have had nutrition training and a nutritional needs update is sent to the kitchen weekly. Care plan interventions follow the Roper Logan and Tierney model of the activities of daily living, which is a commonly used tool. It was noted however that this model does not provide as effective prompts for interventions relating to psychological or emotional needs as physical. For example, the assessment information of one resident describes how she finds it difficult to adjust to new situations and can be anxious, yet the model did not pick this up. It was suggested that it would have been useful to have a care plan intervention relating to this although daily records demonstrate that staff were providing reassurance. The manager agreed that this area could be strengthened and is going to consider how this might be done. Care provided is generally person centred and the home is striving to make continual improvements to the care they provide to make residents feel secure and well cared for. This is something they appear to be achieving well. Staff were observed caring for residents in the lounge and during lunchtime. They responded well to residents who became upset or anxious and offered reassurance and explanations. More attention could be paid to explaining things fully before actions, for example before moving residents or helping people to put clothing protectors on. It was noticed that this could be done quite quickly considering most people are very confused and take time to understand what is happening. It is also recommended that the term “absconding” is avoided when describing the risk of residents leaving the building unsupervised as it can be negative and discourages staff from the positive view that people are at liberty to leave, we just need to ensure they are safe and accompanied. Residents and relatives spoken to said they are very happy with the care provided and that there has been an improvement. There are more robust systems for checking the safety of residents who are checked each half hour during shifts, and the nurse in charge must account for each person at the end of each shift. There was a noticeably more calm and less noisy atmosphere in the home on both days of the inspection which could be attributed to an overall improvement in the well being of residents in the home, due to the good standard of care provided and efforts of staff. Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are very good opportunities for residents to be involved in social activities in the home and meals are also good. EVIDENCE: A good activities programme is in place and this includes group and one to one activities. There is evidence of regular entertainment coming into the home, and residents are encouraged to go out. An open visiting policy is in place. Families and friends are able to visit in private and some residents go out with private enablers. The downstairs dining area has been transformed into a bar at one end and a tearoom at the other. Both are tastefully decorated to feel just like the real thing and it is a popular place for residents. Some men have been using the bar area to watch sports, and Windsor tearoom is open to the public on some days maintaining close links with the community. Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 Page 13 The garden area has been improved and made more accessible and interesting to residents. Research has demonstrated the benefits of people with dementia having access to outdoors so this is a very beneficial improvement. There is now a decked area and rush type matting around the garden provides a degree of privacy with some view of the outside world through it. There is a barbeque area and the home were donated funds for a bench in memory of a resident. There are solar lights and paved areas with good wheelchair access. There is a new sensory room, which contains various visual and tactile equipment. This offers residents further opportunities to explore the environment and on one day of the inspection, a resident who tends to be restless went into the room unaided and sat for a long time looking at the equipment and touching some of the objects. The equipment is also portable which is a good idea as it can be taken to people in their own room if they prefer. Meals are planned in advance and alternative choices are available. Tables are nicely set and the cook is made aware of preferences and changes to dietary requirements weekly. The kitchen is clean and tidy and well stocked. There is a new cooker and the floor was replaced as requested by the environmental health department. The cook has completed a 12-week nutrition training course and also has health and safety and safeguarding adults training. Sugar substitute is used to enable residents with diabetes to enjoy the same desserts as other residents. Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Complaints are responded to very thoroughly and fairly. Good safeguarding adults procedures are in place. EVIDENCE: There were 8 complaints logged since the last inspection ranging from minor to serious in nature. Each complaint was very carefully logged by the home manager, and responded to in line with company policy. Set timescales are followed by which it will be anticipated that the complaint will have been investigated etc. Where this time was going to be exceeded for any reason, the manager advised the complainant in writing. Letters to complainants were written in an extremely sensitive and honest manner. Where there is no evidence to prove the complaint for example, the manager does not simply dismiss the complaint but offers to ensure that the situation will be closely monitored. Where the complaint has been upheld, the manager apologises and outlines in detail the action taken to prevent a reoccurrence. The manager clearly considers how to approach each complaint, as the response to each one is different and sometimes unconventional. There are good procedures in place for the protection of vulnerable adults. Staff receive regular training and any safeguarding issues are alerted promptly and dealt with swiftly. Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is very well maintained and creatively decorated. EVIDENCE: A number of improvements have been to the environment in the home since the last inspection. It has resulted in a home that is not only clean and well maintained but also adapted to make it as homely as possible and include areas of interest. The lounges are very homely, and a three- piece suite has been provided, in addition to the separate existing seating. On both days of the inspection, residents were very comfortable on the chairs and settee, often dozing. The manager told how she had found one resident curled up leaning on another resident. She approached to gently move them in case they were Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 Page 16 uncomfortable or unhappy. The resident being leaned on told her “not to move her” as she was sleeping, and appeared to enjoy the close contact and sense of caring for her which is extremely important for the well being of residents in the home. It also demonstrates that the manager is carefully monitoring changes that are made which is also important. The dining area has, as described above, been transformed into a bar at one end and café/tearoom at the other. There is brewery memorabilia in the bar including and actual bar and pub tables, chairs and beer mats. The tearoom has fine crockery and cake stands, fine milk jugs and teapots to add to the atmosphere. As mentioned, members of the public can come for coffee mornings. A sensory room has been made from an old staff room. There are blackout curtains that can be open or closed and have lights within the fabric. There is a bubble tube and fibre optic lights. There are small egg shaped objects that light up, and one resident had moved these and was happy holding them and looking at them. It is mobile to useful for people who are bed ridden or have severe dementia. Bedrooms are nicely personalised and there are no odour problems in the home. The garden area has been improved with further improvements planned when there is better weather including the planting of a sensory garden. The home is clean and hygienic there were no hygiene issues identified during the inspection. Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are well trained staff on duty in sufficient numbers at all times. EVIDENCE: Staff files checked found that recruitment procedures protect residents as all of the required checks are carried out before employing new staff. Most staff have NVQ level 2 or 3 or are working towards these qualifications. A training matrix and individual training files are available and show staff have received statutory training. A discussion took place about the dementia training currently provided and it was suggested that this is audited to ensure it contains the most up to date information and approaches in the field. There are sufficient staff employed in the home. Bank staff are used at times but the aim of the home is to only use n=bank staff with a knowledge of the home. Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is very effective and professional. EVIDENCE: The manager has been through the fit person process with CSCI and has been found “fit” since the last inspection. There is a strong deputy in post and the home has improved under this management. The manager is experienced and committed and plans to strengthen her knowledge of dementia care by taking a formal course. Staff praised the manager with one saying, “You couldn’t get a better manager”. The morale of Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 Page 19 the staff team has improved since the last inspection and this has had an impact on the whole home. The financial procedures in the home have not changed since the last inspection and are satisfactory. Record keeping has improved in the home and has been strengthened by the Ladhar consistent company approach to record keeping. In house auditing ensures records are kept up to date. There is a full time administrator and a new computer system is in place. Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement 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. Refer to Standard Good Practice Recommendations Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Windsor Court DS0000028829.V356916.R01.S.doc Version 5.2 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. 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