Inspection on 24/05/06 for Windsor Court

This inspection was carried out on 24th May 2006.

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

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

Other inspections for this house

Windsor Court 23/02/10

Windsor Court 09/02/09

Windsor Court 19/02/08

Windsor Court 19/02/07

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Windsor Court The Avenue Wallsend Tyne & Wear NE28 6SD Lead Inspector Aileen Beatty Key Unannounced Inspection 14th June 2006 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.V289709.R01.S.doc Version 5.1 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.V289709.R01.S.doc Version 5.1 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 3422 Mr Baldev Singh Ladhar Mrs Margaret Stevens 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.V289709.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 5. Two of the LD beds are currently occupied by named residents. If resident leaves the home leaves the home no further admissions must take place in this category without agreement of CSCI. One MD bed is currently occupied by a named resident. If resident leaves the home leaves the home no further admissions must take place in this category without agreement of CSCI. One short stay respite bed can be used for one specified resident as agreed category LD, otherwise it is category DE(E). One DE bed is currently occupied by a named resident. If resident leaves the home leaves the home no further admissions must take place in this category without agreement of CSCI. Date of last inspection 7th December 2005 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. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 2 days, the 24th May and 14th June 2006. It involved a tour of the premises, inspection of records, and discussions with staff residents and visitors. There were no comment cards returned from residents or visitors. The inspection found that the overall standard of care is adequate. What the service does well: What has improved since the last inspection? What they could do better: Care records must be kept up to date to ensure the correct care is given at all times. Care records must be kept locked away to keep them confidential. Pressure area care must be improved to prevent them occurring or becoming worse. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 6 Procedures for the administration of medicines must be followed so that they are administered and stored safely. Social care plans and the range of activities available must be improved to ensure that people live fulfilling lives doing things that they enjoy. Some fixtures and fittings in the home need to be replaced to keep it tidy and well maintained. 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 DS0000028829.V289709.R01.S.doc Version 5.1 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.V289709.R01.S.doc Version 5.1 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 the following standard(s): 3 Intermediate care is not provided. Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. A pre admission assessment is carried out before any resident is admitted to the home. EVIDENCE: The manager carries out Pre admission assessments before anyone is admitted to the home. Records for more recently admitted residents show that more information is now included. An information sheet about the person is also now available for most people. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 9 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): 7,8,9 and 10 Quality in this outcome area is poor. This judgment has been made from evidence gathered both during and before the visit to this service. Health, social and personal needs are not always set out in an individual plan of care. Service users health needs are not always fully met. Procedures for dealing with medicines are not always followed. Service users are usually treated with respect but privacy is not always upheld. EVIDENCE: All residents have a file containing information about their care. These care records include assessments of nutritional needs, moving and handling requirements (help with mobility), pressure area risk (sometimes called bedsores) and dependency levels. They also contain care plans that are written using the information from the assessments. These care plans describe how care should be given to people and must be followed by all staff. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 10 A number of assessments were found to be out of date. Some care plans had not been reviewed on time so were also out of date. The care plans for people with pressure sores were out of date. This was a problem in the past but had improved at the last inspection in December 05. Records show deterioration in care plans from February 2006. An Immediate Requirement Notice was issued on 24/05/06 that all care records relating to pressure sores must be brought up to date within 24 hours. This was done but at the second part of the inspection on 14/06/06, it was found that care records for 2 people remained out of date and the improvement had only been sustained for a few days. Turn charts were not filled in on time. A warning letter has been sent to the home about this. In one file there was no record of dentist visits or of missing dentures, which family members had discussed with the inspector. Information in files confirmed that GP and district nurse visits had been recorded and that residents are given access to primary health care professionals. Windsor Court is a specialist unit for people with Dementia. Psychological care plans do not reflect up to date practice in dementia care and must be reviewed. For example, one care plan describes giving a person a clock and telling them the time and where they are throughout the day. This is an outdated method of care called “Reality Orientation” and can further distress people who are confused. It is recommended that nursing staff have access to Journals and refresher training in dementia care to enable them to use up to date knowledge and practices. Residents are generally clean and tidy and appropriately dressed. Staff are caring in their manner towards residents. A hairdresser visits every week. Residents enjoy the experience and it is noticeable that people have nicely styled hair when visiting the home. Medication procedures are not always followed. A medicine trolley was left open and unattended in the lounge, close to where residents were sitting. Morning medication was being given out at 11.30 am which is unacceptable. The Operations director was informed of the concerns on the day of the inspection and agreed to address this as a matter of urgency. Most posters about personal care have been removed from walls as required. One poster was found on the wall of one bedroom. This was to inform staff which type of incontinence pad the person wears and must be removed. New filing cabinets were bought following the last inspection as the old ones did not lock. They are situated in the main corridor so are easy to access. These filing cabinets are regularly left open and care plans left on the desk. This is an outstanding requirement, which has not been met. A shelf in the first floor dining room contains individual fluid charts, turn charts and incontinence forms. Records are inappropriately stored and filed and there is no reason to keep them in the dining room. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 11 Staff were observed to knock on doors and to treat service users with respect and dignity during the inspection. Personal care was provided in service users rooms with the door secured. Bathroom and toilet doors were shut and staff observed to knock before entering. Staff demonstrated knowledge of individuals and use their preferred form of address. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 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 the following standard(s): 12,13,14 and 15. Quality in this outcome area is poor. This judgment has been made from evidence gathered both during and before the visit to this service. Residents do not find the lifestyle experienced in the home matches their social, cultural, religious and recreational interests and needs. Residents may maintain contact with family, friends and the community if they wish. Residents are not always helped to exercise choice and control over their lives. A wholesome appealing and balanced diet is provided. EVIDENCE: The activity coordinator left the home in April this year. The home is currently advertising for a new one. There is little evidence that there are many activities carried out in the home. Staff will take people with them to the shops if they are on an errand, and one person has been helping to care for some tomato plants. Staff describe sing – alongs and spontaneous activities but these are not recorded anywhere. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 13 Staff were observed on the top floor sitting with service users and music was playing, on other floors television provides a background. Social care plans are generally poor. They contain standard statements and are not individualised to take into account the residents past interests, likes or dislikes. Again, these do not demonstrate any specialist knowledge of how to plan activities or meet the social needs of people with dementia. There was a requirement set at the last inspection that staff should receive training in person centred care. This has not been met. Routines of daily living are organised according to the routine of the home. One man was asleep as lunch was served and was coaxed into waking up and attending the dining room. This demonstrates that the routine takes priority which should be reviewed. One person who is mainly bed ridden has recently begun to get up in the afternoon, to enjoy more company. This was problematic as they needed a recliner chair and had to wait until the person using it went to bed for a rest as there was only one available. Another has been ordered. It was also recommended that when people have severe dementia or are bed ridden, staff make sure that they are positioned to see things such as views from a window, favourite photographs and items of interest. Assessments must be carried out to ensure there are sufficient chairs of a suitable type for all residents. There must be a detailed review of the types of activities that should be offered to residents. They should include a good range of group, individual and sensory activities for people with communication problems. Another home in the Ladhar Group has developed a good programme of activities. One idea they had was to stick bird feeders on some windows. Recent research suggests access to nature is essential for the well – being of people with dementia. This is a good example of how this can be achieved for less mobile people. It is recommended that good practice such as this be shared between homes. Visitors are able to visit at any reasonable time of day. They may visit in private. Visitors spoken to said they were generally happy with the care provided. More than one visitor expressed a concern that although the majority of staff are friendly and polite, they had found some staff rude. They said it was particularly if they expressed concerns and felt that they were then branded trouble- makers. It is recommended that staff are offered training in customer care. Residents with learning disabilities have enablers who visit to help them to exercise choice over their lives. Residents are not always given choices about all aspects of their lives. A radio was playing Century FM, which is mainly pop music. One resident agreed that Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 14 this could be switched off saying “thank goodness”. It appeared that this was for the benefit of staff not residents, which is unacceptable. Meals are ordered the day before, but when meals were being served there appeared to be no referring to the list to see what people had chosen. Some staff said that they do, others do not. There was a discussion about whether residents could be offered choices on the day, which would reduce the risk of them changing their mind. It would also mean that the choices could be shown to them on a plate, which may help people with communication problems. Some people may benefit from picture menus. Some additional information about alternatives for Diabetics would be useful. The alternative dessert for people with Diabetes is usually yoghurt or fruit, although the cook prepares sugar free custard and jelly specifically for service users with diabetes. This is not offered as an alternative each day. The standard of meals is good. Residents appear to enjoy meals and the cook is aware of special diets. It is recommended that there is a system for ensuring the cook has been brought up to date with the most recent information. For example if someone loses weight, in addition to seeking appropriate advice, there should be a trigger to advise the cook to ensure supplemented meals are available. The kitchen is clean, tidy and well organised. There seemed to be good supplies of food available. It was noted that all yoghurts are low fat, and full fat may be more beneficial as many people experience weight loss. The cook was not aware that it is good practice to puree food separately or that moulds may be used to reform individual items of a meal. The cook agreed that pureed food was not very appealing when done all together but said that the person for whom this was prepared ate it anyway. The cook has not had any specialist training in nutrition and diet for people with dementia and would be interested in taking part in training. The cook commented that the trays provided to keep vegetables warm were too large and often vegetables had to be transferred into a dish and kept warm in the trolley rather than in the bain marie, this makes the vegetables soggy and over cooked. There are two heated trolleys to serve three floors in Windsor Court; consequently people on the first floor must wait until those on the ground floor have received their hot meal. It is recommended that this is reviewed. One lady was observed self consciously wiping her mouth on her petticoat, as no napkins were available. These should be provided. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 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 and 18 Quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. Residents and relatives are sometimes confident their complaint will be listened to and acted upon. Service users are protected from abuse. EVIDENCE: There have been four complaints since the last inspection. These have all been investigated and responded to by the manager within 28 days. Two were upheld and two were partially upheld. They relate mainly to missing and damaged clothing and property. Relatives said that they found the manager very friendly and helpful but were aware that she was working reduced flexible hours so said they did not wish to disturb her. Should these hours continue, visitors must be reminded who they should speak to in the manager’s absence. A Criminal Records Bureau check is carried out before staff are employed in the home. There have been no new POVA (protection of vulnerable adults) referrals. Staff have received POVA training in the last 12 months. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 16 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, 24 and 26. Quality in this outcome area is poor. This judgment has been made from evidence gathered both during and before the visit to this service. The environment is not always well maintained. Not all service users live in safe comfortable surroundings with their own possessions around them. Not all areas of the home are satisfactorily clean. EVIDENCE: There are a number of outstanding requirements from the last inspection. The broken shower plug in the middle floor bathroom has not been fixed. Bare bedrooms and bathrooms have not been made homely or warm in appearance. An immediate requirement notice was issued on 24/05/06 due to a section of corridor carpet that was frayed and lifting. This has been fixed and made safe. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 17 Two people in the home have MRSA; laundry is washed separately and at high temperatures to prevent cross infection. The laundry is managed effectively with a dedicated laundry worker; more individual laundry baskets are required to ensure that each resident’s laundry items may be kept in order. This is an outstanding requirement from the last inspection. Relatives expressed concern about missing items of clothing and buttons from service users clothes which is being dealt with as a complaint by the manager. Some areas in the home are shabby in appearance. The hem was down on the curtains in one room, and bedding is often mismatching. There remains inadequate storage in some en suite toilets. In two toilets the handrails were being used upright to store rolls of toilet paper. Two toilets did not have soap, lidded bins or hand towels available. Light cords in all bathrooms were dirty. The bathroom on the middle floor smelt. The shower room on the middle floor was dirty and contained three smelly chairs; a broken showerhead and a broken plug in the base of the shower. The blinds in the shower room were dirty and broken. A number of carpets were found to be dirty, but it was explained that the carpet cleaner had been broken and there was a delay in receiving a replacement machine. The Operations Director and administrator for the home carried out an audit of all rooms and furniture. An action plan is being written detailing work that needs to be carried out. The bedroom of one resident who is nursed in bed the majority of the time, was found to be bare with possessions placed out of sight. Staff must ensure that people who are nursed in bed receive appropriate stimulation, and the layout of the room should be carefully considered. Staff agreed to rearrange this room and suggested moving the bed to improve the view. There has been some improvement to the cleanliness in the home. Cleanliness in en suites has improved. The treatment room is also clean and tidy. Some furniture is badly marked and the arm of a chair in one bedroom was so encrusted with food that it could be scraped off with a pen. There was no flip top on one clinical waste bin. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 18 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): 27,28,29,30 Quality in this outcome area is adequate. This judgment has been made from evidence gathered both during and before the visit to this service. There are sufficient staff on duty. Service users are in safe hands at all times. Service users are supported by the homes recruitment policies and practices. Some staff are trained and competent to do their jobs. EVIDENCE: There are sufficient staff working in the home. One the day of the inspection, they were fully staffed, with 1 RMN & carer on ground floor, 1 RMN who is also the deputy & 3 care assistants on first floor, 3 carers on second floor. There was 1 cleaner, 1 cook, and 1 laundry worker. The administrator was at another home as she is a shared resource. The manager reported that she is pleased with the way her new team are working together. Staff changes have improved morale and are encouraging staff to work better together. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 19 The manager was not present for part of the inspection, so there was no supernumerary manager on duty. Staff appeared confused as to who was in charge or when the manager would be in. There is a vacancy for an activities coordinator and for a cleaner within the home. These are being covered by staff from other homes at present. All staff have attended adult protection training. The recruitment process requires that all staff have a criminal record check before working in the home. Staff training has been provided in COSHH (hazardous substances) moving and handling, and adult protection and some First Aid. Training is being arranged in infection control for nurses. Health and safety, and training in person centred care needs to be arranged. Competency of nursing staff needs to be assessed in relation to pressure area care, and psychological care planning for people with dementia. It is strongly recommended that managers monitor how nurses maintain their own professional development. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 20 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 Quality in this outcome area is poor. This judgment has been made from evidence gathered both during and before the visit to this service. The home is not always managed satisfactorily. The home is not always run in the best interest of service users. Service users financial interests are safeguarded. The health safety and welfare of service users is generally protected. EVIDENCE: It has been necessary in recent months for the manager to work reduced hours. Staff do not always appear to know who is in charge, and the deputy lacks sufficient knowledge of what is happening in all areas in the home due to working as a nurse. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 21 The deputy is currently managing the home and is working supernumerary (is not working as part of the staff complement). The Operations Director is visiting the home twice a week to provide support. The management of the home must improve. There are ongoing concerns about nursing care and requirements that are outstanding from the previous 2 inspections. Resident’s money was randomly audited and found to be correct. The manager acts as appointee for 2 service users. This is to be reviewed, as it is not usual practice within the Ladhar group. Staff supervision must be brought up to date. The home is generally safe. An immediate requirement notice was issued, as a carpet in the middle floor corridor was frayed and lifting, causing a tripping hazard. This was repaired and made safe. Health and safety training is being arranged. Safety inspections have been carried out by gas, electrical, passenger lift, and water safety contractors in the past 12 months. Poor nursing practices in relation to the administration of medicines and pressure area care has compromised the health and safety of residents. Security is poor in the home. It was possible to walk straight into the home on both inspection days. On the first day of the inspection, two inspectors were present. Care staff did not challenge this. Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 22 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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 2 X 2 Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 23 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 OP7OP7 Regulation 15 (1) 17 (1) (b) 2 3 4 OP8 OP9 OP10 15 (1) 13 (2) 12 (4) (a) Requirement Care plans must be kept up to date Care records must be stored confidentially. OUTSTANDING Care plans must reflect current best practice in dementia care. Medication procedures must be followed. Information relating to personal care needs must not be publicly displayed. Advice must be given to staff about why this is not appropriate. OUTSTANDING Suitable group, individual and sensory activities must be provided. Person centred social care plans must be developed for all residents. An action plan must be provided detailing action to be taken following audit of environment. New laundry baskets must be provided and broken ones removed. OUTSTANDING Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 24 Timescale for action 24/05/06 24/07/06 14/06/06 24/07/06 5 OP12 16 (2) (m) 24/07/06 6 OP19 13(2)13 (3)23(2) (d) 24/07/06 Chairs must be removed from the shower room. Bathroom must be made more homely in appearance. Bedroom layout must be carefully considered for people who are nursed in bed. 7 8. OP14 OP15 12 (3) 16 (2) (i) 12 (3) Radio programmes must be appropriate and selected by residents. A choice of meals must be offered to all residents at every mealtime. Napkins must be provided. Pureed meals must be prepared and presented as individual food items. Suitable storage must be supplied in en suite toilets. OUTSTANDING All areas of the home must be kept clean. Hand towels soap and bins with lids must be provided in toilets. Dirty pull cords must be replaced. All staff receive training in person centred care and infection control. OUTSTANDING Nurses must attend refresher training in dementia care and tissue viability. The manager must complete the registered managers award by 31/12/06 The manager must audit the home environment regularly. DS0000028829.V289709.R01.S.doc 24/07/06 24/07/06 9. OP21 23 (2) (l) 24/07/06 10 OP26 13 (3) 24/07/06 11. OP30 18(c)(i)10 (3) 24/08/06 12. OP31 9 (2) (i) 31/12/06 13. OP32 24 (1) (a) 24/07/06 Page 25 Windsor Court Version 5.1 OUTSTANDING 14. OP33 24 (1) (b) 24 (3) Review Quality Assurance systems OUTSTANDING 24/07/06 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 OP28 Good Practice Recommendations It is recommended that the manager monitors the training carried out by qualified staff in order to meet registration requirements (Prep) OUTSTANDING The manager attend accredited training in person centred care. OUTSTANDING Alternative dessert ideas are sought for diabetics. Good practice in activity planning and delivery is shared within the company. Provide training to staff about maximising independence and avoiding rigid routines. Review seating requirements of all residents. Review arrangements for the serving of meals from 2 trolleys. Staff receive training in customer care. 2. 3. 4. 5. 6. 7. 8. OP32 OP15 OP12 OP14 OP19 OP15 OP33 Windsor Court DS0000028829.V289709.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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. 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