Inspection on 06/06/05 for Windsor Court

This inspection was carried out on 6th June 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 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 24/05/06

Windsor Court 07/12/05

Windsor Court 02/11/04

Windsor Court 10/05/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

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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 Unannounced 06 June 2005 09:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Windsor Court Address The Avenue Wallsend Tyne & Wear NE28 6SD 0191 2635060 0191 2621989 N/A Mr Baldev Singh Ladhar Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Margaret Stevens CRH 45 Category(ies) of DE Dementia (2) registration, with number DE(E) Dementia - over 65 (35) of places LD Learning disability (3) MD Mental disorder (1) MD(E) Mental disorder - over 65 (4) Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 3 of the LD beds are currently occupied by named residents. If any of these residents vacate the beds the CSCI must be notified, when action will be taken to revert those places to the category of DE (E)1 MD bed is currently occupied by a named resident. Once this resident leaves the home the CSCI must be notified, when action will be taken to revert that place to the category of DE (E)One short stay respite bed can be used for one specified resident as agreed category LD, otherwise it is category DE (E) Date of last inspection 02/11/04 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, conveniently adjacent to the High Street, giving ease of access to shops, stores, restaurants and other public amenities. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 7.5 hours. A tour of the premises was conducted and records examined. Residents were joined for lunch. The inspection found the overall standard of care to be satisfactory. What the service does well: 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3. Service users have their needs assessed prior to moving into the home. Intermediate care is not provided. EVIDENCE: Care records for the most recently admitted resident were examined. They contained all of the required information. Assessment information is available before admission. Staff in the home also carry out their own pre-admission assessment. The residents spoken to felt that they were well cared for and that their needs were being met. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10. Care plans are not always up to date. Service user health needs are nearly always met. Medication procedures are not satisfactory. Service users are mostly treated with dignity and respect. EVIDENCE: The overall format of care plans are due to be replaced. This will be a good opportunity to remind staff to put dates on all entries including assessments. A daily record is kept about every resident. Some assessments such as nutritional rating scales, and behaviour rating scales were completed but not dated. Some were dated but then not evaluated regularly. Many areas were only partially completed. The lack of regular monitoring of health needs means it is not possible to always fully be aware of the exact status of residents health. Some care plans written were of a good standard and some had been signed by residents or their relatives. Residents spoken to during the inspection, who were able to comment, said that they are well cared for. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 9 Medication records were examined and some gaps in recording noted. If medicine is not given for any reason a code must be used. A random check of Temazepam – a controlled drug, found that they were correctly stored and the right amount was available. The clinical room was found to be dusty with clutter on surfaces. The Fridge and room temperatures have not been recorded regularly. Two suction machines were noted to be dirty. One was not accessible in an emergency. Dates must be written on eye drops when opened. In the main residents are treated with dignity. Staff are generally discreet when offering help with personal care, and were observed knocking on doors before entering rooms. Personal information relating to residents is publicly displayed in a number of areas in the home. A toileting programme was observed pinned to a wall. A picture relating to bowel care was also pinned on the notice board in the dining area. This compromises the dignity of residents. The fact that staff would pin such information up in public implies that they do not see the home as a domestic environment. Some training is required to remind some staff of the need to maintain a homely environment, and to think about what they would find acceptable in their own homes. Notice boards with information for staff should not be pinned in residents living areas. Most areas in the home are very domestic and homely in style, however, and staff encourage residents to bring in their own belongings. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13 and 15. Recreational needs are met by the home. Service users are encouraged to maintain contact with family, friends and the community. A balanced diet is provided. EVIDENCE: A list of forthcoming activities was displayed. A good range of activities was noted. Entertainers are sometimes brought into the home. New personal profiles are in place which will assist staff to develop more personalised activities based on information about past likes, dislikes and experiences. A number of residents are supported by enablers. Residents are able to receive visitors at any reasonable time. Residents were joined for lunch by the inspector. The meal was tasty and well presented. It was served at an appropriate temperature. No napkins were provided and there were no drinks served or offered during the meal. Menus are provided on a 4 weekly cycle. The kitchen staff explained that they are given the choices of residents a week in advance. It is suggested that this may be too far in advance for people to know what they would like. It is particularly difficult for people with dementia to recall what they have ordered. It is recommended that alternative ways of offering choices are considered. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 11 The kitchen was inspected. Sufficient supplies of food are available. Fresh fruit and vegetables are delivered every other day. The Kitchen was clean and hygienic. Kitchen staff are appropriately trained. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. Complaints are dealt with seriously by the home. Service users are protected from abuse. EVIDENCE: A satisfactory complaints procedure is in place. There have been 3 complaints since the last inspection. They have been appropriately recorded. Complaints records were examined and found to be satisfactory. The complaints procedure is publicly displayed. Staff receive training in adult protection and procedures, including whistle blowing are available. Some adult protection issues have been raised and the home are cooperating fully with the Protection of Vulnerable Adult proceedings. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26. The home is generally safe and pleasant. It is not always clean and hygienic. EVIDENCE: A number of items of furniture have been replaced since the last inspection. There is an ongoing programme of redecoration, and the manager is aware of further maintenance issues. Most areas are homely and well maintained. Some bedding was found to be mismatching, with missing valances, giving an untidy look. New bedding was shown to the inspector which should improve this. New towels and crockery have also been ordered. Some carpets in identified bedrooms are malodorous and must be replaced. Some furniture is badly marked and dirty. This was pointed out to the manager during the guided tour of the premises. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 14 Some en suite bathrooms were found to be quite cluttered, making cleaning difficult. The drawers in one identified bedroom must be replaced. It was noted that the flooring in the lift was being replaced the following month. The carpet in the lounge on the middle floor is frayed and needs to be replaced. The basin in the toilet opposite room 11 is cracked and needs to be replaced. There is also a cracked basin opposite room 41. The grout in the middle floor shower room is dirty, the plug is damaged. The banister opposite this room needs to be replaced. The home was not found to be satisfactorily clean during the inspection. Some areas, including en suite bathrooms, were found to be very dusty. Clutter was found in some en suites, making it particularly difficult to clean these areas. A number of chairs were badly marked. Poor hygiene practices were noticed in some areas. 1. There was dirty underwear lying in the laundry sink. The hand washing sink in the laundry was very dirty. 2. Toilet brushes in some rooms were very dirty. 3. A drawer belonging to a resident was opened and contained a lot of items that should have been discarded including a wet incontinence pad. This may be unavoidable, given the confusion of some residents. The general state of the drawer however, indicated that it had not been cleaned for some time. 4. Towels are stored in bathrooms which is inadvisable due to dampness and potential for contamination. 5. Flip tops are missing from some bins. 6. Clinical waste bins should be operated by foot pedal. 7. The clinical room must be kept dust free and clear of any inappropriate items. Surfaces should be easy to clean. It is the responsibility of nurses to ensure the clinical room is clean. 8. Fridge temperatures are not always recorded. 9. The sluicing disinfector is not in use. The home must demonstrate that this does not pose any health hazard. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 15 The home manager was made aware of the poor standard of cleanliness which appears to have deteriorated recently. She agreed to address this issue promptly. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30. There are satisfactory numbers and skill mix of staff. The homes recruitment policies and practices support and protect service users. Staff appear trained and competent to do their jobs. EVIDENCE: Staffing rotas were examined. Staffing was found to meet minimum staffing levels required. Staffing levels may vary depending upon vacancies in the home. The home’s recruitment policies and procedures are satisfactory. Staff records show that all of the required information is in place. There are satisfactory numbers of qualified and unqualified staff. CSCI have been notified of any staffing difficulties, and the action taken to ensure the safety of residents is maintained. Staff supervision has not been carried out on a regular basis. Now that the manager has returned from long term absence, it is expected that the recent move towards getting staff supervision up to date will continue. All staff are due to receive adult protection training. 5 staff are booked to complete NVQ level2, 4 are booked to do level 3 and 1 is booked to do the Registered Managers Award. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 17 There is a quick reference form in each staff file regarding training received, which is a useful aid to planning. Staff also complete self competency assessments, which is good practice. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35 and 38. The home is managed by a person fit to be in charge. Financial inetersts of service users are safegaurded. The health, safety welfare of service users is generally protected. EVIDENCE: The manager has been absent for a long period from work. The inspection occurred soon after her return. It is acknowledged that there is a period of settling back into work and getting up to date with events during the time off, therefore it was necessary to allow for this. The manager and deputy cooperated fully during the inspection. The manager is registered with the Commission for Social Care Inspection so is regarded as competent to manage the home. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 19 Resident’s money was randomly checked and found to be correct. There were very large quantities of coins, and it is recommended that the system be reviewed to make it easier to manage. There are health and safety policies and procedures in the home. Statutory training such as fire safety and manual handling is provided. Some health and safety issues were identified during the inspection, in addition the hygiene that may affect health, outlined under standard 26. 1. Pull cords in a number of rooms are tied up. 2. The flooring in toilet 1 on the ground floor could cause a tripping hazard. 3. Eggs are not stored in the fridge. It should be confirmed that this meets current advice. 4. Domestic staff interviewed had no COSHH training (Control of substances hazardous to health). 5. The key was left in the cleaning cupboard. 6. The suction machines in the clinic were dirty and not easy to access in an emergency. Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 2 Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 21 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7, 8 Regulation 15 (1) (2)(b)(c) (d) 13 (2) Requirement Care plans and assessment infromation must be brought up to date, and training provided. OUTSTANDING Medication records must be accurately maintained. Dates must be recorded when opening eye drops. Information relating to personal care needs must not be publicly displayed. Advice must be given to staff about why this is not appropriate. Methods of offering choices for meals muct be reviewed. Drinks should be offered with meals. The following areas must be addressed by the home. An action plan must be submitted relating to the following:-Some carpets in identified bedrooms are malodorous and must be replaced. Some furniture is badly marked and dirty. This was pointed out to the manager during the guided tour of the premises. Some en suite bathrooms were found to be quite cluttered, Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 22 Timescale for action 1st October 2005 Immediate 2. 9 3. 10 12 (4) (a) Immediate 4. 15 16 (2) (i) 1st September 2005 1st September 2005 5. 19 making cleaning difficult. The drawers in one identified bedroom must be replaced. It was noted that the flooring in the lift was being replaced the following month. The carpet in the lounge on the middle floor is frayed and needs to be replaced. The basin in the toilet opposite room 11 is cracked and needs to be replaced. There is also a cracked basin opposite room 41. The grout in the middle floor shower room is dirty, the plug is damaged. The home was not found to be satisfactorily clean during the inspection. Some areas, including en suite bathrooms, were found to be very dusty. Clutter was found in some en suites, making it particularly difficult to clean these areas. A number of chairs were badly marked. The action plan must detail how 1st the following areas identified will September be addressed. 2005 1. There was dirty underwear lying in the laundry sink. The hand washing sink in the laundry was very dirty. 2. Toilet brushes in some rooms were very dirty. 3. A drawer belonging to a resident was opened and contained a lot of items that should have been discarded including a wet incontinence pad. This may be unavoidable, given the confusion of some residents. The general state of the drawer Version 1.20 Page 23 6. 26 23 (2) (d) Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc 7. 38 13 (4) (a) however, indicated that it had not been cleaned for some time. 4. Towels are stored in bathrooms which is inadvisable due to dampness and potential for contamination. 5. Flip tops are missing from some bins. 6. Clinical waste bins should be operated by foot pedal. 7. The clinical room must be kept dust free and clear of any inappropriate items. Surfaces should be easy to clean. It is the responsibility of nurses to ensure the clinical room is clean. 8. Fridge temperatures are not always recorded. 9. The sluicing disinfector is not in use. The home must demonstrate that this does not pose any health hazard. Immediate The action plan must detail how the following safety issues will be addressed. 1. Pull cords in a number of rooms are tied up. 2. The flooring in toilet 1 on the ground floor could cause a tripping hazard. 3. Eggs are not stored in the fridge. It should be confirmed that this meets current advice. 4. Domestic staff interviewed had no COSHH training (Control of substances hazardous to health). 5. The key was left in the cleaning cupboard. 6. The suction machines in the clinic were dirty and not easy to access in an emergency. Ensure care staff receive formal supervision at least six times a year. Outstanding. Immediate 8. 9. 30,36 18 (1) (c)(i) (2) Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 24 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 Good Practice Recommendations Windsor Court B53-B03 S28829 Windsor Court V221797 060605 Stage 4.doc Version 1.20 Page 25 Commission for Social Care Inspection 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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