Inspection on 07/12/05 for Windsor Court

This inspection was carried out on 7th December 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 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 Unannounced Inspection 12th December 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 DS0000028829.V272979.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 DS0000028829.V272979.R01.S.doc Version 5.0 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 262 1989 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.V272979.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mrs Stevens is a registered mental nurse. She does not possess a management qualification but intends to undertake an NVQ 4 in management. This qualification should be achieved by 2005. One short stay respite bed can be used for one specified resident as agreed category LD, otherwise it is category DE(E). 2 of the LD beds are currently occupied by named residents. If any of these residents vacate the beds, the Commission for Social Care Inspection must be notified, when action will be taken to revert those places to the category DE(E). 1 MD bed is currently occupied by a named resident. Once this resident leaves the home the Commission for Social Care Inspection must be notified when action will be taken to revert that place to the category DE(E). 1 DE bed is currently occupied by a named resident. Once this resident leaves the home the Commission for Social Care Inspection must be notified when action will be taken to revert that place to the category DE(E). 6th June 2005 2. 3. 4. 5. Date of last inspection Brief Description of the Service: Windsor Court is a purpose built three storey Care Home providing both Nursing and Residential care for up to 45 service users. Categories of care are Dementia, Learning Disabilities and Mental Disorder. The home provides care for service users above and below 65 years of age. The home is situated in The Avenue, Wallsend, conveniently adjacent to the High Street, giving ease of access to shops, stores, restaurants and other public amenities. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 2 days, the 7th and 12th of December. The inspection involved a tour of the premises, checking of records and discussions with residents staff and relatives. The overall standard of care is satisfactory. What the service does well: What has improved since the last inspection? Some furniture has been replaced since the last inspection. Medication procedures have improved. Staff supervision is being carried out on a regular basis. The standard of information recorded about pressure area care in particular, has improved. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 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.V272979.R01.S.doc Version 5.0 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): 4. Standard 6 is not applicable as intermediate care is not provided. The home is able to meet assessed needs of most individuals admitted to the home. EVIDENCE: The home provides specialised care for people with dementia. There are residential and nursing beds. Registered Mental Nurses are employed in the home. Training is provided in dementia care and challenging behaviour, in addition to statutory training. Some practices in the home tend to be institutionalised and demonstrate a lack of insight into the effects this may have on people with dementia. For example, residents were not offered a choice of drinks at lunch time as the carer knew “they all like tea”. The inspector, who joined residents for lunch, was offered tea, coffee, water juice or lemonade. Studies have shown that when small but important choices are taken away from people, they may lose, more quickly, the capacity and motivation to make choices for themselves. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 Page 9 The deputy manager expressed an interest in carrying out some research to help to update the current training offered. It is recommended that this be followed through. It is also recommended that the manager monitors, through supervision, the ways in which qualified staff keep up to date with current best practice and carry out the training required to maintain their nurses registration. Some staff were observed approaching residents in a very warm and caring way. In the dining room the member of care staff was also seen trying to console a very distressed person. Good strategies of approaching and withdrawing when the person became angry, and then approaching again a little later were used with good effect. A number of staff do demonstrate good core skills. The concern is that a culture appears to be emerging of “one size fits all” and this should be challenged at every level so that the good care practices are not undermined. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9, and 10. The service user’s health, personal and social needs are set out in an individualised plan of care. Medication procedures are generally satisfactory. Service user’s are not always treated with respect nor their right to privacy upheld. EVIDENCE: 4 care plans were examined and found to be of a good standard. Particular attention was paid to the recording and monitoring of wound care and pressure sore prevention and care. Good practice was demonstrated in the recording of wound care. Photographs of wound size are available with measurements and these are dated and signed. Care records are not maintained securely as filing cabinets do not have locks and are stored in a public place. A confidential hospital letter was lying out on the desk in the main corridor. An immediate requirements notice was served and new filing cabinets are being purchased. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 Page 11 Nutritional and pressure area risk assessments were completed. Turn charts and food and fluid balance were commenced for people deemed at risk. On the first day of the inspection it was found that these had not been filled in. The inspector was told by staff that they would fill them in later when they had time. For example, one resident being nursed in bed had been turned twice by the day shift. By 13.10.p.m. the chart had still not been started for that day. The same applied to the fluid balance charts. An immediate requirement notice was issued which included that records must be completed at the time of intervention and no later. The Operations manager for the home has reinforced this with all staff. On the second day of the inspection, all records were found to be up to date. An activities co-ordinator is in post and various activities are arranged. It may be useful to include the views of the activities co-ordinator when assessing social care plans. Medication procedures were found to be generally satisfactory. Some prescribed creams were found in the wrong residents bedrooms. These were removed and discarded. Another tube of cream was removed which was over 3 years out of date. Systems for ordering of medication are satisfactory. It was noted that there is no contract in place for the disposal of medication, in line with recent changes in legislation. This was brought to the attention of the deputy manager. There is no alarm on the controlled drugs cupboard. This was brought to the attention of the deputy manager who agreed to find out if this is a legal requirement. An audit of controlled drugs was satisfactory. A requirement set at the last inspection relating to suction machines remains outstanding. The broken one should be removed. The other must be kept clean and ready to use in an emergency. The treatment room was a little cluttered and should be kept clean and free of unnecessary items, especially on the window sills. This helps with keeping the room clean and dust free, aiding control of infection. A requirement was set in respect of this at the last inspection. This has not been met. The water was extremely hot in the treatment room, making effective hand washing impossible. There were no hand towels in the dispenser. While some staff do try to maintain the dignity and privacy of residents, some staff do not. One member of staff in particular was repeatedly seen entering bedrooms and never knocking. Incontinence pads are not stored discreetly, and information relating to intimate care is sometimes publicly displayed. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 Page 12 Notices displayed in the communal living areas of the home contribute to making the home feel institutionalised. One poster threatens staff with disciplinary action if they fail to attend training, and another relates to continence training. It was felt by the inspector that these would be more appropriately placed in a staff room, particularly the latter which related to a potentially embarrassing complaint which some residents may prefer not to have public attention drawn to. The manager in the home disagreed with the inspector regarding this issue. There is an outstanding requirement from the last inspection, which states that personal information must not be publicly displayed, and training provided as to why this is not appropriate. The lack of progress in this area is disappointing and urgent action is required. Inappropriate use of the private facilities of a resident was discovered during the inspection. This was immediately pointed out to the manager who agreed to address this with staff. Again, this demonstrates a lack of respect. Residents wear their own clothing at all times and are generally clean and tidy in their appearance. Windsor Court DS0000028829.V272979.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): 14 and 15. Service users are sometimes helped to exercise choice and control over their lives. A wholesome appealing and balanced diet is provided, with some areas for improvement in service recommended. EVIDENCE: In a number of ways, residents are offered choices and helped to have some control over their lives. It was noticed, for example, that more able residents may attend reviews of their care and sign care plans. As described above, some practices in the home prevent choices from being made. Residents were joined for lunch. The meal was tasty and well presented. The menus are displayed in dining rooms. Unfortunately the wrong week out of the four week menu cycle was displayed on all floors in the home. All residents must be offered a choice of drinks at each meal time. The kitchen was not inspected during this visit but was satisfactory at the last inspection. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 A complaints procedure is in place. Adult protection procedures are in place. EVIDENCE: There are no complaints recorded since the last inspection in May 2005. Staff have received training in adult protection, and there have been no new POVA (Protection of vulnerable adults) referrals. An action plan was submitted to the adult protection panel following the last POVA referral, outlining how the home planned to deal with a particular situation. This included the provision of specific training within a time limited period. Due to a change in circumstances of the individual involved, the manager has extended the deadline of the action plan. The inspector has requested written confirmation of this change and suggests that action plans should not be changed as it is part of a formal process, without informing the POVA team. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. Not all areas in the home are safe or well maintained. There are sufficient lavatory facilities. The home is not sufficiently clean or hygienic. EVIDENCE: A tour of the premises was conducted. All communal areas, bathrooms and most bedrooms were inspected. Main lounge areas were warm and homely and decorated for Christmas. The carpet join between the lounge and corridor carpet on the middle floor is frayed. This must be repaired or replaced. Some bedrooms and bathrooms were very bare and clinical. The manager said that she had been told in the past that bathrooms must be kept clear of any unnecessary items including blinds and pictures. While it is true that it is recommended that towels are not stored in damp bathrooms due to infection control, the inspector was unable to find a previous requirement to remove pictures. The manager was encouraged to use her own discretion and Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 Page 16 challenge advice of inspectors if she felt she had good reason to. At present the bathrooms are cold and uninviting. During the inspection, a resident required assistance to use the toilet. The staff member left the bathroom to correctly obtain an apron. Unfortunately the resident was unable to wait until they returned. It was recommended that in order to prevent similar accidents, essential equipment required on a daily basis such as gloves or aprons should be stored in the bathroom. Items should only be stored in small quantities and replaced daily to avoid contamination. The plug in the middle floor shower room remains damaged. This is an outstanding requirement from the last inspection. Bedrooms and in particular, en- suite facilities are not cleaned to a high standard. The toilets do not have satisfactory storage for toiletries and old food cartons from the kitchen had sometimes been utilised for this purpose. One such gravy container was found to contain dirty teeth, various creams and lotions which did not belong to the resident or were out of date. There was thick dust and grime in the bottom of the container. Teeth were also found in other rooms in a dirty state and lying on basins. The shelves below sinks in en suite bathrooms were very dirty and dusty. No bins were available for the disposal of hand towels in some en suite facilities. A used catheter bag was found on the floor of an en suite toilet. An immediate requirements notice was served on 07/12/05 requiring the home to clean these rooms to a satisfactory standard. Disappointingly, these remained dirty at the inspection, which was essentially announced, on 12/12/05. Poor cleanliness was identified at the last inspection and the requirement to improve it remains outstanding. The inspector has given the home the opportunity to make improvements in hygiene and infection control. An infection control audit by a suitably qualified person will be requested by CSCI to assess progress in this area in the coming months. This audit will be unannounced. The laundry was found to be clean and tidy but there were some things on the floor, due to the lack of laundry baskets. The one that was in use was damaged and must be replaced. It is recommended that individual baskets are used to store individual residents clothing. The laundry staff member said that this would be very helpful. The staff member interviewed said that she does not have a current COSHH certificate. This should be updated as she is dealing with chemicals. It was noted that some linen towels and face cloths were worn and frayed and must be replaced. Sponges with no names were discarded. There was some malodour in identified bedrooms. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 Page 17 Bags of clothing and incontinence pads in large boxes cluttered up some bedrooms and en suite facilities. Pads should be stored elsewhere until needed. Some bedroom furniture in bedrooms is damaged and needs to be replaced, including missing drawers and general tattiness. Names on bedroom doors are often untidy labels and messily written. It is strongly recommended that neat and legible name signs are attached to bedroom doors. Externally, there was a lot of rubbish, including food waste strewn around. This was cleaned up during the inspection. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 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, 29 and 30 Service user’s needs are met by the numbers and skill mix of staff. Service user’s are in safe hands at all times. The homes recruitment policies and procedures protect service user’s. Most staff are trained and competent to do their job. EVIDENCE: On the day of the inspection there were 6 care staff instead of 7 due to sickness. The manager was sick, and the deputy manager was acting as the RMN (Registered Mental Nurse) for the shift. This meant that there was no supernumerary manager but this was not expected to continue for a long period of time. The home continues to operate within agreed staffing levels, sometimes exceeding the minimum. The manager confirmed that when agency staff are used, qualified nurses may be employed to cover for care staff in extreme emergencies to ensure minimum numbers are maintained. Some staff spoken to felt that the home is short staffed and that this adds to pressure of completing records properly etc. They were advised that this should be raised with the management in the home. Earlier this year, it was discovered that the registration status of one of the qualified nurses had lapsed. Since then, systems have been put in place to ensure this is monitored and does not happen again. The home took appropriate action and reported the incident to CSCI. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 Page 19 Staff files for the most recently recruited staff members were examined. They contain the required information. A new system will see staff files being audited by the manager 6 monthly. There was evidence that disciplinary action is taken against staff who fail to attend statutory training. The training plan for November was seen and contained moving and handling, first aid, fire safety, POVA (protection of vulnerable adults), induction, Movicol (laxatives). Continence promotion and food hygiene training has been arranged. Some staff require additional training, particularly relating to person centred care and control of infection / hygiene. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 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, 32, 33, 36, and 38. The home is managed by someone fit to be in charge and of good character. The ethos, leadership and management of the home requires some work. The health, safety and welfare of service users are not always safeguarded. EVIDENCE: The manager has not yet completed the registered managers award and is approximately half way through. She anticipates that this will be completed by the end of 2006. The manager is registered with the Commission for Social Care Inspection so is currently regarded as competent to manage the home. A number of requirements set at the last inspection remain outstanding. This is disappointing and the manager must demonstrate a more proactive approach to meeting the requirements set. On the 7th December, a number of immediate requirements were set, including that all en suite facilities must be thoroughly cleaned. On the 12th December, the inspector found that they were still dirty. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 Page 21 The manager was shown the dirty areas and accompanied the inspector for part of the tour. It is surprising that these areas were not thoroughly checked by the management team prior to the planned re-inspection. It is strongly recommended that all qualified staff on each shift monitor the cleanliness of the home. The manager must carry out a regular check of the premises to ensure satisfactory standards are being maintained. It is strongly recommended that the manager, deputy and qualified staff attend training in person centred care. Free accredited training has been sourced by other homes in the area from the local college and it has assisted them to positively challenge some of their own beliefs and attitudes. This would enable structured training to be cascaded to staff in the home. The whole philosophy of care and ethos should be underpinned by these principles. Examples of institutionalised practices of some staff, and the way in which the dignity of some people has been seriously compromised demonstrates that this is an urgent training need. Requirements relating to these areas also remain outstanding from the last inspection and a significant improvement is necessary. It is encouraging that the manager has recognised the seriousness of some of the examples of bad practice and disciplinary action has been taken. This will only prove beneficial if it is followed up by training and support about why certain behaviour is unacceptable. Quality assurance systems in the home were not fully assessed during this inspection. It is apparent, however, that these systems should be reviewed as a number of the areas identified for improvement during this inspection would have been picked up by a robust system of quality monitoring. It is recommended that systems are reviewed and some means of customer satisfaction monitoring carried out. This is a challenging area due to the fact that a number of residents could not contribute to a survey of their views. Staff supervision was found to be up to date for October and November, so this is an improvement. A requirement was set at the last inspection so this has been met. The home must demonstrate that this can now be sustained but it is a positive improvement. The home is generally safe and well maintained. It was found that a number of wardrobes were not secured to the walls and an immediate requirement notice issued. These were secure by 12/12/05. The number of accidents recorded for the period of 12/11/05 and 12/12/05 is 40. For the month of October to November 47 are recorded. This includes some staff accidents but still appears somewhat high. The manager confirmed that accidents are not analysed on a regular basis. It is important that this is carried out on a monthly basis as per Ladhar group procedures. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 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 X 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 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 2 2 2 X X X X 2 Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 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 2 3 Standard OP4 OP7 OP19 Regulatio n 12 (1) (a) 17 (1) (b) 13(2)13 (3)23(2) (d) Requirement Timescale for action 12/12/05 Service users must be assisted to maintain their independence at all times. Care records must be stored 07/12/05 confidentially. 07/02/06 The following must be met in relation to medication and treatment room. • It must be clarified whether it is a legal requirement to have an alarm on the controlled drugs cupboard. If so this must be provided. • A contract for the disposal of medicines in line with current legislation must be obtained. • The broken suction machine must be removed. The other must be easily accessible in an emergency. OUTSTANDING • Water temperature in the treatment room must be adjusted to enable effective hand washing. • Hand towels must be available at all times. • The clinical room must be kept dust free and clear of DS0000028829.V272979.R01.S.doc Version 5.0 Windsor Court Page 24 • • any inappropriate items. Surfaces should be easy to clean. It is the responsibility of nurses to ensure the clinical room is clean. OUTSTANDING Damaged bedroom furniture must be replaced. OUTSTANDING The lounge carpet on the middle floor is damaged and needs replaced. OUTSTANDING 12/12/05 4 OP10 12 (4) (a) 5 OP15 6 7 OP18 OP19 Residents must be treated with respect by all staff. Information relating to personal care needs must not be publicly displayed. Advice must be given to staff about why this is not appropriate.OUTSTANDING 16 (2) (i) All residents must be offered a choice of drinks at meal times. Accurate menus must be displayed. 13 (6) The POVA chair must be notified of any changes to action plans agreed by them. 23(2)(d)1 The following improvements must 6(2)(k)x be made to the environment. • The join between the lounge and corridor carpet on the middle floor is frayed and must be repaired or replaced. • Bare bedrooms and bathrooms must be made more homely. • The damaged plug in the middle floor shower room must be replaced. OUTSTANDING • New laundry baskets must be provided and broken ones removed. • Excessive quantities of pads must not be stored in bedrooms and en suites. DS0000028829.V272979.R01.S.doc 12/12/05 12/12/05 12/03/06 Windsor Court Version 5.0 Page 25 8 9 OP21 OP26 23 (2) (l) 13(3)23 (2)d 16 (2)f 10 OP38 13(4)(a) 13(4)(c) 18(c)(i) 10 (3) 9 (2) (i) 24 (1) (a) 24 (1) (b) 11 12 13 14 OP30 OP31 OP32 OP33 Worn linen and towels must be replaced. • Names on bedroom doors must be written neatly and preferably typed. Suitable storage must be supplied in en suite toilets. The following measures must be taken to improve hygiene in the home. • The home must be kept clean at all times. • The treatment room must be kept clean and clutter free. OUTSTANDING • Malodour in identified bedrooms must be addressed. • Bins must be provided for the disposal of hand towels. • The water temperature in the treatment room must be adjusted to allow effective hand washing. • Catheter bags must be disposed of correctly at all times. • Teeth must be stored in containers. • Baskets should be provided to allow individuals clothes to be sorted and kept separately. Accidents must be analysed on a monthly basis. All staff handling chemicals must have up to date COSHH training. All staff should receive training in person centred care and infection control. The manager must complete the registered managers award by 31/12/06 The manager must audit the home environment regularly. Review Quality Assurance systems DS0000028829.V272979.R01.S.doc • 12/02/06 12/12/06 12/12/05 12/03/06 31/12/06 12/12/05 12/03/06 Windsor Court Version 5.0 Page 26 24 (3) 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 Refer to Standard OP28 OP32 Good Practice Recommendations It is recommended that the manager monitors the training carried out by qualified staff in order to meet registration requirements (Prep) The manager attend accredited training in person centred care. Windsor Court DS0000028829.V272979.R01.S.doc Version 5.0 Page 27 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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