Inspection on 26/08/05 for Windsor Court

This inspection was carried out on 26th August 2005.

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 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 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 18/11/05

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 26th August 2005 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 DS0000032192.V249295.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.V249295.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 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.V249295.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 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 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. The home provides a large car parking area at the front for visitors. Windsor Court is owned by Lyndale Ltd, a family business. 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 a stair lifts. Aids and equipment are available for residents who may have disabilities, including ramped access to and from the home and five portable hydraulic bath seats to facilitate bathing for service users requiring such assistance. The home is centrally heated throughout. All of the fortythree bedrooms are for single occupancy, with thirty-seven 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.V249295.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 6.75 hours on the 26th August 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. A tour of the premises took place and records and related documentation were examined including the care records for four residents. Time was spent observing the interaction between residents and staff, as well as talking with eighteen residents, Mr Glanville, the Senior Care Manager and the staff on duty, in order to get a real feel of what it is like to live at Windsor Court. What the service does well: Written information about Windsor Court is available for prospective residents and their relatives or representatives, to let them know what they can expect from the home and help them decide if Windsor Court is right for them. Pre-admission assessments are carried out to ensure that only people whose needs can be met are offered places within the home. Prospective residents are informed of the outcome of these assessments in writing, so they are assured that their care needs can be met. Prospective residents and their relatives have opportunities to visit the home in order to assess the quality of facilities and its suitability for their needs. Health care needs are well met. Care staff are supported in caring for residents by community healthcare professionals, such as GPs, district nurses, chiropodists, opticians etc. Residents feel that they are treated with respect and their right to privacy and dignity is promoted at all times. Some activities are provided and a weekly inter-denominational communion service is held within the home. Open visiting arrangements are in place, so residents are able to maintain contact with visitors whenever they wish. A balanced and varied selection of food is served and residents speak highly of the meals provided. We have a good breakfast, then cooked lunch and cooked tea as well if we want it. They look after us very well here”. I think that the food is pretty good here. The staff always come and ask what I want to eat and there is always a choice. If I don’t like what is on the menu, the chef will make me something else”. Residents may choose where in the home to eat their meals and the timing can be flexible to fit in with visitors, appointments and care needs etc. Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 6 Residents are confident that complaints would be listened to and dealt with appropriately. No complaints had been received by the home or the Commission since the last inspection. The home provides access to a choice of attractive communal areas, including a garden. Facilities and equipment are available to ensure that residents are enabled to maximise their independence. Bedrooms are comfortably furnished and individually personalised by their occupants and all have access to ensuite facilities. Residents commented, I am very comfortable here, I like my room very much. “This place has more than lived up to my expectations. I have everything I need in my room”. Windsor Court is clean throughout and there are no unpleasant odours. Suitable procedures are in place in respect of laundry. Windsor Court employs enthusiastic staff, most of whom are experienced in caring for people. Residents speak highly of the staff, We could not ask for nicer people to look after us. Most of them are extremely kind and patient. An experienced management team works hard to ensure that residents receive a consistently high standard of care. A resident commented, The managers are doing a good job. This place is very well run. The home regularly reviews its performance through the use of Quality Assurance questionnaires and takes action in response to comments and suggestions made. Staff are well supervised to ensure they are meeting the needs of residents. What has improved since the last inspection? What they could do better: Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 7 To ensure resident safety, the Medicine Administration Record (MAR) charts need regular updating; the audit trails for some medicines need improving and the monitoring of medication requires further development. Many residents are satisfied with the activities provided in the home, but some say they would like a greater variety of activities and more entertainment to be arranged. Although the home has a comprehensive Adult Protection policy, not all staff have received training in adult protection issues to ensure a proper response to any suspicion or allegation of abuse. More attention is needed to carrying out staff fire training and fire drills at the required intervals, to ensure staff know the action to take in the event of fire. 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.V249295.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.V249295.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): 1, 3 and 5 Standard 6 is not applicable to Windsor Court. Information provided about Windsor Court and a thorough admissions procedure allows prospective residents to make informed decisions about admission to the home and ensures that only those whose needs can be met are offered places there. The home assures prospective residents in writing that their needs can be met. Prospective residents and their relatives have opportunities to visit the home in order to assess the quality of facilities and its suitability for their needs. EVIDENCE: The Brochure, Statement of Purpose and Service User Guide contain information about the home and its facilities. The Service User Guide gives a good indication of what a resident can expect from the home and is available in each residents bedroom. Individual care records are kept for each resident and two of these were examined for recently admitted residents. The records showed that, prior to moving to Windsor Court, care needs had been fully assessed. A form has Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 10 been developed for this purpose and is now being implemented. The registered manager or the senior care manager generally carries out all preadmission assessments. A letter of confirmation is then written to the prospective resident so that they may feel fully assured their care needs will be met. The information contained in the pre-admission assessments and also any assessment supplied by Social Services, is then used to draw up a detailed plan of care. Prospective residents and their relatives are encouraged to visit Windsor Court to assess the facilities available, meet other residents and staff and have an opportunity to discuss their particular care needs. A trial period of four weeks is available. Although reference to a trial period is made in the terms and conditions or contract, it is suggested that further information detailing the opportunities for prospective residents to visit the home, sample meals etc, as well as arrange a trial period etc, be included in the Service User Guide, to fully reflect current good practice. Windsor Court DS0000032192.V249295.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): 8, 9 and 10 Health needs are well met, with evidence of good support from community health professionals. 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. Residents are treated with respect and their privacy and dignity is promoted at all times. EVIDENCE: All four of the care plans examined detailed the particular health care needs of each resident. Daily care notes support and evidence the delivery of care to residents. These are well detailed and give a good picture of the care provided, visits by community health professionals and relatives etc. Records demonstrate that residents have access to GPs, district nurses, opticians, dentists, chiropodists, the Speech And Language Therapy Team etc Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 12 and attend hospital appointments as necessary. This was confirmed by residents and observed during the inspection. Risk assessments are in place and appropriate steps are taken to ensure any risks identified are minimised. The Commission for Social Care Inspection Pharmacy Inspector, Miss Christine Main, also visited Windsor Court on 26/8/05 to inspect the medication arrangements. Updates to the medicines policy were seen but procedures for when a doctor changes medication verbally had not been added. Residents can self-administer their medicines if they wish and are able to. A system for reviewing risk assessments has been introduced. From observation and discussion with staff the current procedure for administering medication involves some re-dispensing of medicines, which is not recommended. The home uses a monitored dosage system and Medicine Administration Record (MAR) charts printed by the pharmacy. A sample of five MAR charts was checked with the medicines in stock. There was a medicine on one MAR chart that had been discontinued some time ago and the home should liaise with the pharmacy to ensure that MAR charts are regularly updated. Some changes to medicine directions were not clearly recorded and these were improved straight away. The audit trails for some medicines checked agreed with the records. For others there was no audit trail. The senior care manager has recently monitored the records and audit trails for two antibiotics. Two boxes of one medicine contained more capsules than originally dispensed but batches of a medicine dispensed on different occasions must not be mixed as this may lead to potential for claims under product liability. Two medicines checked were labelled “as directed” and the GP should be asked to include full directions on the prescription. Staff were observed throughout the inspection to be treating residents with courtesy, patience, kindness and respect. Staff always knocked at bedroom doors and toileting activities were carried out discreetly. Residents commented, The staff here are very good. They are mostly very polite and respectful. The staff always knock on my door before coming into my room. When I arrived, they asked me how I wanted to be addressed. Residents are able to go to their rooms at any time, thereby offering an opportunity to be on their own if they wish, or allowing privacy for any visitors or personal care needs. Residents commented, I can go to my room whenever I wish, it is my room. I can go to my room and if I say I dont wish to be disturbed, they respect that. Windsor Court DS0000032192.V249295.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 and 15 A range of activities and events provide variation and interest for residents to help satisfy their social, religious and recreational needs. However, some residents would like to see a wider range of activities and entertainment available. Residents are encouraged to maintain contact with family and friends and the wider community. Windsor Court serves a balanced and varied selection of food that meets residents’ tastes and special dietary needs within a variety of pleasant surroundings. EVIDENCE: A flexible approach is taken to the running of the home to fit in with residents needs and wishes. A range of activities is available at Windsor Court. These include a variety of board games, a weekly gentle exercise class to music, quizzes, bingo and a weekly tea dance. Some residents like to play the piano. The mobile library visits each month. Occasional local outings and theatre trips are arranged. Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 14 An inter-denominational service is held within the home every Sunday. Residents confirmed that they were happy with the current arrangements. I can watch the television, read or do a crossword. Sometimes I enjoy a game of Scrabble. We can do whatever we like here. There are no rules here, we can please ourselves. I like to look at the notice board to see what is going on in the home. It is good that we have a religious service and communion on Sundays.” However, some residents said they would like a wider range of activities and more entertainment within the home. The Senior Care Manager is aware of this from the recent Quality Assurance questionnaires and is currently looking at ways of achieving a greater range of activities and entertainment. Mr Glanville says visitors are made welcome at any reasonable time and residents confirm that visiting times at Windsor Court are unrestricted. Residents records and the visitors book demonstrate contact with family and friends as well as visits by professionals. Some 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. Lunch on the day of inspection was steamed fish with parsley sauce, chipped or mashed potatoes, sweetcorn and peas. This was followed by a choice of almond and cherry sponge with custard, tapioca pudding or prunes and custard. The chef demonstrated knowledge of individual likes/dislikes and said alternatives could always be provided to suit individual taste and preference. Mealtimes are seen as social occasions. In the dining room, the lunch was served in a relaxed, unhurried atmosphere with discreet staff assistance provided wherever necessary. Residents may choose to eat their meals in the dining room, TV lounge, bar area or in their bedrooms. In good weather, meals may also be taken in the garden if wished. Mealtimes are flexible to fit in with care needs, appointments etc. The menu shows that residents enjoy a healthy, well-balanced diet. Fresh fruit and vegetables are used wherever possible. Special diets are catered for. Residents spoke highly of the food provided and the following comments were received: The food is excellent, it could not be better. I think that the food is pretty good here. The staff always come and ask what I want to eat and there is always a choice. If I don’t like what is on the menu, the chef will make me something else”. They feed us too well! I have put on weight since I came here. We have a good breakfast, then cooked lunch and cooked tea as well if we want it. They look after us very well here”. On the whole, we have very good food here. I cant complain about the food. Windsor Court DS0000032192.V249295.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 and 18 A system is in place for dealing with any complaints. Residents are confident complaints would be listened to and dealt with appropriately. 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 in their bedrooms. A copy of the complaints policy is also available to visitors in the entrance hall. No complaints have been received by the home or the Commission since the last inspection. Contact with residents and visitors demonstrated they would feel able to voice a complaint and felt that their concerns would be taken seriously, and acted upon. Comments included: I dont have any complaints about this place, none at all”. If I did want to complain, I would speak to someone straight away but I have never had to complain about anything here”. 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, it is necessary to ensure that all staff have received training in Adult Protection issues to ensure Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 16 a proper response to any suspicion of abuse. Mr Glanville says such training is currently being planned. Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 17 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, 20, 22, 24 and 26 Windsor Court provides an attractive, well-maintained and comfortable environment for residents. Considerable investment is planned for the future improvement and refurbishment of the home. However, failure to ensure staff fire training and fire drills are always carried out at the correct intervals has the potential to place residents, staff and visitors at risk in the event of fire. The home provides access to a choice of attractive communal areas, including gardens for residents to enjoy. Residents have the facilities and equipment necessary to maximise their independence. Bedrooms are comfortably furnished and individually personalised to suit their occupants. Windsor Court is clean with no unpleasant smells, making daily life more pleasant for all in the home. EVIDENCE: Inspection of the premises confirmed that routine maintenance is being carried out. Since the last inspection, the flat roof area has been re-felted, a new sluice room created and new industrial washing machines and tumble dryers installed in the laundry. A programme of refurbishment has commenced with Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 18 twelve bedrooms undergoing redecoration, the replacement of some items of furniture and the fitting of new carpets. Detailed maintenance records are kept and maintenance staff ensure prompt attention to defects etc, whenever necessary. Hot water temperatures at baths were tested and found to be close to the recommended temperature of 43C, to prevent any risk of scalding. All radiators in public areas are guarded to ensure residents safety. It is intended to fit guards to all radiators as part of the planned refurbishment. Records demonstrate regular servicing of equipment, such as hoists, passenger lift and stairlift. Fire records show appropriate checks being carried out on the fire warning system, emergency lighting and fire fighting equipment. However, documentary evidence was not available to confirm staff fire training and fire drills being carried out at the required intervals, to ensure that staff are fully aware of what to do in the event of fire. An Immediate Requirement Notice was issued. (The Commission has subsequently received confirmation that these matters have been attended to satisfactorily.) 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. There is also a large garden available to the rear of the home and patio tables, chairs and umbrellas are available for those wishing to sit outside. Access to the garden will be improved when the refurbishment is completed. An Occupational Therapist has carried out an assessment of the facilities and specialist equipment available at Windsor Court and is satisfied that the home meets Standard 22 of the National Minimum Standards for Care Homes for Older People. A range of adaptations and facilities installed in the premises promote the independence of residents and ensure that they also receive assistance in a way that ensures their dignity. These facilities include: A ramp at the entrance enabling wheelchair access, passenger lift and stair lifts, raised WC seats, mobile hoists and an alarm call system to enable residents to summon staff if necessary. A tour of the building confirmed that residents bedrooms are comfortably furnished and personalised to varying degrees. Residents commented, “I have not been here long, but I have a lovely room and was able to bring some of my furniture with me”. I am very comfortable here, I like my room very much. “This place has more than lived up to my expectations. I have everything I need in my room”. The home is clean and there are no unpleasant smells, making life within the home more pleasurable. Suitable facilities and procedures are in place in respect of laundry and the disposal of clinical waste. Residents commented, My room is always kept very clean. They keep the whole place very clean and tidy. The laundry is very reliable. We usually get everything back very quickly. Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 19 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 The numbers and skill mix of staff are sufficient to meet the needs of residents. However, staffing levels will need to be kept under review if the care needs of residents increase. Staff morale is good, resulting in an enthusiastic workforce that works positively with residents to enhance their lifestyles. EVIDENCE: Examination of the staff rota and observation throughout the inspection demonstrated a sufficient number and skill mix of staff to meet the current needs of residents. At the time of inspection, the following care staff were on duty: 07:45 a.m. to 14:00 p.m. 14:00 p.m. to 20:00 p.m. 19:45 p.m. to 08:00 a.m. - 7 care staff. - 5 care staff. - 3 care staff (wakeful). The home also employs chefs and kitchen staff, maintenance and domestic staff. In general, residents and staff felt that the staffing levels were satisfactory although, on occasion, more care staff would be beneficial. Residents commented, The staff are very good to us. Even when they are very busy, they are still cheerful. The staff work hard. I think they are a bit thin on the ground sometimes. We could not ask for nicer people to look after us. Most of them are extremely kind and patient. There are always Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 20 staff around when you need them. Staff said, We make a good team here. Most of the time we have enough staff, but it does get very busy sometimes. As the care needs of residents increase, we sometimes require more staff to meet these needs, but on the whole we manage very well. Relationships between staff and residents were directly and indirectly observed throughout the course of the inspection. They were friendly and relaxed, whilst remaining professional. Staff appeared enthusiastic in their work. One member of staff commented, I enjoy working here. We only have to provide care for the residents and not do cooking and cleaning. Residents commented, The staff are OK here. You can enjoy a laugh with them sometimes, which is good. They are lovely people here. They look after us very well indeed. The staff are very kind. Nothing is too much trouble for them. Following the last inspection, a requirement was made about the recruitment procedure. Although Standard 29 was not fully inspected on this occasion, three staff files were examined and found to have the required checks in place to ensure the protection of residents. Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 21 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, 32, 33 and 36 An experienced management team works to ensure that residents receive a consistently high standard of care. Clear leadership is provided throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The home 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. Staff are well supervised, to ensure they are fulfilling their role satisfactorily and meeting the needs of residents. EVIDENCE: Mrs 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 and also Mr James Glanville, on behalf of Lyndale Ltd. All five members of the management team have experience in caring for older persons. Two have nursing qualifications and two have the Registered Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 22 Managers Award. One has the National Vocational Qualification (NVQ) level 4 in care. The Senior Care Manager is currently working on defining individual and shared management tasks to ensure the smooth running of the home. Windsor Court has a friendly, relaxed and welcoming atmosphere, which is beneficial to residents, staff and visitors alike. 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 evident throughout the day. Discussions with staff show that they are clear about their roles and responsibilities within the home and feel they are important members of the team. They speak positively about members of the management team. You can always speak to a manager if you want to. We all get on well together. We are all part of the team working for the benefit of our residents. Residents commented, The owners are very nice people, I enjoy a chat with them. The managers are doing a good job. This place is very well run. A recent letter from a relative was seen and this stated, Any organisation is only as good as the manager is in charge, which to me shows just how well you run your home. Policies and procedures are available to offer guidance to staff. The staff team includes individuals from countries other than the United Kingdom and the home has a written policy about equal opportunities. Managers and staff frequently spend time talking with residents informally to obtain their views. It is hoped to produce a Windsor Court newsletter in the near future, to keep everyone in touch with what is happening in the home. 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. It is intended that questionnaires will also be produced for other visitors to Windsor Court. The home also receives a number of letters and compliments from the relatives and friends of residents. For example, Thank you for looking after my relative with so much care and dignity. We are all very grateful for your patience and kindness. Your staff go beyond their job description in terms of their caring and compassionate outlook towards residents. Formal staff supervision has now been implemented and will take place every two months. Monthly staff meetings also provide opportunities for staff to express their views and ideas. Staff appraisals are carried out annually to assess any training needs, ensure they are fulfilling their role satisfactorily and are meeting the needs of residents. Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 23 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 X X Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 24 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. 1 Standard OP9 Regulation 13(2) Requirement The current procedure for administering medicines must be reviewed so that medicines are not re-dispensed in advance of administration. The home must have a clear audit trail for all medicines not in MDS blister packs by dating packs when they are started or entering a carry forward balance on the Medicine Administration Record (MAR) chart. Batches of a medicine dispensed on different occasions must not be mixed; they must be kept in the labelled container they were supplied in. 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 persons must ensure that staff fire training is carried out at the recommended intervals, i.e. every 3 months for night staff and every 6 months for day staff and be fully recorded. DS0000032192.V249295.R01.S.doc Timescale for action 31/10/05 2 OP9 13(2) 31/10/05 3 OP9 13(2) 31/10/05 4 OP18 13(6) 31/12/05 5 OP19 23(4)(d) 23/09/05 Windsor Court Version 5.0 Page 25 6 OP19 23(4)(e) The registered persons must ensure that fire drills are carried out at the recommended intervals, i.e. every 6 months and be fully recorded. 23/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP9 OP9 OP9 OP12 Good Practice Recommendations 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 the GP should be asked to include full directions on prescriptions for medicines labelled “as directed”. It is recommended that Medicine Administration Record (MAR) charts should be kept up to date and discontinued items removed, or clearly marked as such. It is recommended that residents are consulted about their interests to ensure a suitable programme of activities and entertainment is provided. Windsor Court DS0000032192.V249295.R01.S.doc Version 5.0 Page 26 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. 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