Inspection on 09/01/07 for Windsor Court

This inspection was carried out on 9th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 12/02/08

Windsor Court 31/10/07

Windsor Court 15/06/07

Windsor Court 14/06/06

Windsor Court 18/11/05

Windsor Court 26/08/05

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 6NJ Lead Inspector Marjorie Richards Key Unannounced Inspection 09:50 9th January 2007 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 DS0000032192.V317075.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000032192.V317075.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windsor Court Address 34 Bodorgan Road Bournemouth Dorset BH2 6NJ 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 info@win-court.co.uk www.win-court.co.uk Lyndale Healthcare Limited Mrs Jacqueline Seeborun Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places DS0000032192.V317075.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 2006 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 43 older people. The home has a 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 secluded garden at the rear of the home that is mainly laid to lawn, surrounded by mature trees and a large car parking area at the front for visitors. Windsor Court is owned by Lyndale Healthcare Ltd, a family business. Building works and a programme of refurbishment are currently taking place, updating facilities and improving the standard of accommodation. 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 stair lifts. Aids and equipment are available for residents who may have disabilities. The home is centrally heated throughout. All of the forty-three bedrooms are for single occupancy, with thirty-eight 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. A monthly inter-denominational religious service takes place in the home. DS0000032192.V317075.R01.S.doc Version 5.2 Page 5 The fees for the home, as confirmed to the Commission for Social Care Inspection (CSCI) at the time of inspection, range from £420 - £456 per week. Additional charges include hairdressing, chiropody, dry cleaning, toiletries and newspapers. The Office of Fair Trading has published a report highlighting important issues for many older people when choosing a care home, e.g., contracts and information about fees and services. The CSCI has responded to this report and further information can be obtained from the following website: http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_ choosing a care home .aspx A copy of the home’s inspection report will be made available to anyone wishing to read it upon request to the manager. DS0000032192.V317075.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 8.25 hours on the 8th January 2007. The main purpose of this inspection was to look again at all of the key National Minimum Standards and check that the residents living in the home were safe and properly cared for. Progress in meeting requirements and recommendations from the previous inspection was also checked, as well as monitoring the current building work and refurbishment programme. On the day of inspection, 40 residents were accommodated, including one who is currently in hospital. A tour of the premises took place and records and related documentation examined, including the care records for four residents. Time was spent observing the interaction between residents and staff, as well as talking with a total of thirteen residents. The daily routine was also observed during the inspection. Discussion also took place with Mrs Jacqueline Seeborun, the newly registered manager and members of staff on duty. Mr James Glanville made himself available for part of the inspection, on behalf of Lyndale Healthcare Limited and this was appreciated. For the purposes of this report, people who live at Windsor Court are referred to as residents as this is the term generally used within the care home. The Inspector was made to feel very welcome in the home throughout the visit What the service does well: Assessments of care needs are carried out with prospective residents before they move into the home. This means that residents can be assured their care needs will be met. Multi-disciplinary services such as to General Practitioners, district nurses, dentists, chiropodists, opticians etc are also involved in the care of residents. Open visiting arrangements are in place and residents are encouraged to keep in touch with relatives and friends. Residents are able to choose their own lifestyle within Windsor Court and their individual preferences and routines are respected. They are able to bring their own possessions into the home to personalise their bedrooms. Residents may choose where to eat their meals and mealtimes can be flexible to fit in with care needs, appointments etc. Special diets are catered for and discreet staff assistance is available for those who need help with their food. DS0000032192.V317075.R01.S.doc Version 5.2 Page 7 Staff are kind and helpful to residents. Residents are treated with respect and their privacy is protected. Residents feel safe and well cared for. Residents commented, I think I am well cared for here, the staff are very good. I choose where I go and when and my wishes are respected. The staff are kind to me and very helpful. Nothing is too much trouble. They are keen to help whenever required. I think the staff are excellent, I cannot praise them enough. What has improved since the last inspection? Eight of the 12 requirements made at the last inspection have been met. The remaining four requirements are in the process of being met. The one recommendation from the last inspection has also been put into practice. Mrs Seeborun has been appointed as the new registered manager and has worked hard to deal with the issues raised during the last inspection. She has introduced a new care planning system and re-written all care plans. Mrs Seeborun says that now, wherever possible, care plans are agreed and signed by the resident themselves, or if not, by a relative or representative. Care plans are also being regularly reviewed and updated as necessary to reflect any changing needs. Mrs Seeborun has spoken with residents to obtain their views regarding social activities. A member of staff has now been appointed as activities organiser for five hours each weekday and a programme of activities is being developed. The home is currently being refurbished and the building of an extension is also in progress, to provide better facilities for residents. The home is working to achieve the target of at least 50 trained members of care staff with National Vocational Qualification (NVQ) level 2, to ensure residents at Windsor Court are in safe hands. Improvements have been made to the recruitment process and staff training programme. Mrs Seeborun has recently distributed Quality Assurance questionnaires to residents, to obtain their views about the home. Plans are in hand to send out similar questionnaires to staff, relatives and other visitors to the home. An audit of staff training has been carried out and an overview document produced which clearly identifies the training achieved by all staff in the home and where further input is needed. It is hoped that all staff will have completed essential and mandatory training by the end of March 2007. DS0000032192.V317075.R01.S.doc Version 5.2 Page 8 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000032192.V317075.R01.S.doc Version 5.2 Page 9 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 DS0000032192.V317075.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Windsor Court. Pre-admission assessments are carried out so residents are assured that only those whose needs can be met are offered places there. The home confirms in writing with prospective residents that their needs can be met. EVIDENCE: Individual care records are kept for each resident and four of these were examined, including those of recently admitted residents. Where the Local Authority makes placements at Windsor Court, assessments are carried out by care management personnel from the funding authority and these are also passed on to the home prior to admission. Mrs Seeborun confirms that she herself, or occasionally members of her management team, carries out pre-admission assessments for all prospective residents to determine whether the home can meet their care needs. DS0000032192.V317075.R01.S.doc Version 5.2 Page 11 The records demonstrate that prior to moving to Windsor Court, such preadmission assessments have taken place. At the last inspection, the need for more detailed pre-admission assessments was highlighted. A comprehensive format is now used for this purpose and provides much more detailed information. Following the homes pre-admission assessment, a letter of confirmation is written to the prospective resident so that they may feel assured their care needs will be met. DS0000032192.V317075.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to Windsor Court. A good start has been made in implementing a new care planning system, which aims to ensure that staff have the information they need to meet the needs of residents. There is evidence of good support from community health professionals in meeting health care needs. Medicines prescribed by doctors are safely stored and carefully administered by trained staff to ensure the protection of residents. Residents are treated respectfully and care is offered in a way that protects their right to privacy and dignity. EVIDENCE: Since taking up her appointment as manager, Mrs Seeborun has introduced a new care planning system and has worked hard to re-write all care plans. Care records for four residents were examined. They inform how care is to be delivered to meet residents’ personal and healthcare needs. Assessments DS0000032192.V317075.R01.S.doc Version 5.2 Page 13 have been carried out and specific risks are recorded. Corresponding care plans are being produced, outlining how these risks are to be minimised. Less information is available to show that residents’ psychological, social, cultural or religious needs have been fully considered and appropriate support provided, as necessary. Where residents have specialist needs, such as short-term memory loss or confusion, there is more limited information about how to meet such care needs. Subsequent meetings, observation and discussions with residents demonstrate that care is being delivered as detailed in care plans. Some of the residents spoken with were not yet aware of their care plans. Mrs Seeborun says that she is now working to ensure that care plans are agreed and signed by the resident themselves, or if not, by a relative or representative. It is intended that residents or their representatives, will also be involved in any subsequent changes to their care plans. Care plans are being regularly reviewed and updated as necessary to reflect any changing needs. They also demonstrate that residents have access to General Practitioners, district nurses, dentists, chiropodists, opticians etc. The home has systems in place for managing medicines. Only senior staff deal with medication and they first undertake a course of related training. Medicines are stored securely, to ensure the protection of residents. Part of a medication round was observed during the inspection. The member of staff took proper care to check the accuracy of each medicine before administering it to the respective resident and on each occasion secured the medicine trolley to ensure no medicines could be removed or tampered with. Records indicate that residents are receiving their medicines as prescribed. Staff were seen to knock at bedroom doors and to offer personal care discreetly. Staff interact with residents in a friendly and caring manner. It was clear from the time spent with residents that they feel comfortable and at ease with staff. Staff were seen throughout the inspection to be treating service users with respect, courtesy and kindness, with due regard for the preservation of dignity. Residents commented, The staff have a difficult job to do and most of the time I feel they do it very well. “I think I am well cared for here, the staff are very good. Residents confirm that they are able to spend as much time in their own bedrooms as they wish, thereby offering an opportunity to be on their own or allowing privacy for any visitors or personal care needs. A resident commented, I choose where I go and when and my wishes are respected. DS0000032192.V317075.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to Windsor Court. The range of activities and entertainment is currently being improved to provide variation and interest for residents. Open visiting arrangements are in place and residents are encouraged to maintain contact with family and friends and the wider community. Residents are able to choose their own lifestyle within the home and their individual preferences and routines are respected. Residents are generally satisfied with the standard of food provided. However, improvements are being planned to ensure residents have a greater variety of meals and more choice on the menu. EVIDENCE: Only very basic information about the social, cultural and religious needs of people moving into the home is currently recorded in assessments and care plans. However, Mrs Seeborun is considering ways of obtaining more detailed information, for instance by involving residents and/or their relatives or DS0000032192.V317075.R01.S.doc Version 5.2 Page 15 representatives in the preparation of “Life Histories,” giving background information about each resident’s social history, hobbies and interests etc. Such information will help to ensure that the home can meet individual needs and wishes. During recent inspections, residents commented that they would like to see a wider range of activities available at Windsor Court. Mrs Seeborun has spoken with residents to obtain their views and a member of staff has now been appointed as activities organiser for five hours each weekday. A programme of activities is being arranged. Shopping trips have been organised and some residents attended a local pantomime. Residents recently enjoyed a Gala Night in the home. Mrs Seeborun said that feedback from residents indicated that they would like this to become a regular event. On the day of inspection, a group of residents met together as part of an art and crafts group. It was noted that some of the materials used, e.g. colouring books, were originally designed for use by children. Mrs Seeborun says she intends to source more appropriate materials in due course. Mr Glanville says visitors are made welcome at any reasonable time. Residents records and the visitors book demonstrate contact with family and friends as well as visits by professionals. A few residents are able to go out of the home alone and others with their families or friends. A telephone is available for any residents wishing to make phone calls. Some residents have their own telephones installed in their bedrooms so they are easily able to keep in touch with relatives and the wider community. Residents are encouraged to choose their own lifestyle within the home and make choices wherever possible. These include choosing when to get up or go to bed, what to wear, how to spend their time, what to eat or drink and also freedom to come and go as they please. They are able to bring their own possessions into the home to personalise their bedrooms. Residents confirmed that their individual preferences and routines are respected. Residents may choose where to eat their meals and mealtimes can be flexible to fit in with care needs, appointments etc. Special diets are catered for and discreet staff assistance is available for those who need help with their food. Lunch on the day of inspection was chicken and leek soup, followed by fish pie with green beans and tomatoes, then apple pie and custard. Alternatives are available to suit individual taste and preference. Residents confirm that an alternative is always offered if there is something on the menu they do not like. Residents made a variety of comments about meal provision: I think the meals are excellent. I would like to have more choice, but the food is very good here on the whole. The food is not too bad, a bit monotonous sometimes. I enjoy most of my meals. The food we have is DS0000032192.V317075.R01.S.doc Version 5.2 Page 16 very good, but sometimes it is not very hot by the time it gets to my room. (The temperature of food was highlighted at the last inspection.) We have a very good cook and our meals are very enjoyable. The food lacks imagination sometimes. Too many milk puddings. The food is what I would call satisfactory, but it can be rather repetitive. I dont think the food is as good as it used to be. The food is first-class, I can thoroughly recommend it. Mrs Seeborun confirmed that she is aware of the concerns being voiced by some residents. She is planning to provide hot trolleys to ensure that food remains hot when conveyed from the kitchen to other areas of the home. She is also currently working on improvements to the variety of meals offered on the menu and the introduction of greater choice. Plans are in hand for the enlargement and complete refurbishment of the kitchen and work will commence shortly. Suitable alternative arrangements have been made for the provision of meals during this time. DS0000032192.V317075.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to Windsor Court. A system is in place for dealing with any complaints. Residents are confident that complaints would be listened to and dealt with appropriately. The home has an Adult Protection policy in place to ensure residents are protected from possible abuse. EVIDENCE: The home has a complaints policy and procedure that is included in the Service User Guide provided to all residents. A copy of the complaints policy is also available to all visitors on the notice board in the entrance hall. The complaints record shows that two complaints have been received by the home since the last inspection. One was substantiated, one partially substantiated and appropriate action taken as a result. Discussion with residents demonstrates they feel able to voice concerns if necessary. Comments include: The care here is very good, there is nothing to complain about.” If I was worried about anything, I would tell the staff or the manager and let them sort it out.” I have been here a long time and Ive never had cause to complain about anything at all. DS0000032192.V317075.R01.S.doc Version 5.2 Page 18 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. During successive inspections requirements have been made for all staff to receive training in Adult Protection issues, to ensure a proper response to any suspicion of abuse. (Previous timescales of 31/12/05, 28/02/06 and 30/09/06 not met.) Mrs Seeborun says that the majority of staff have now received Protection Of Vulnerable Adults training and further training is planned for the remaining staff shortly. This requirement is therefore repeated at the end of this report with an extended timescale. DS0000032192.V317075.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to Windsor Court. Windsor Court provides a comfortable environment for residents. The building of an extension and a programme of refurbishment of the home is currently in progress to provide better facilities for residents. Windsor Court is clean with no unpleasant smells, making daily life more pleasant for all in the home. EVIDENCE: Inspection of the premises confirms that routine maintenance is being carried out. Maintenance records are kept and maintenance staff ensure prompt attention to any defects identified. Records also demonstrate regular servicing of equipment, such as hoists, passenger lift and stairlifts to help ensure a safe environment for residents. DS0000032192.V317075.R01.S.doc Version 5.2 Page 20 Windsor Court is an attractive period property, which has been adapted for use as a residential care home. A refurbishment plan is now in progress, which includes redecoration and re-carpeting, the covering of all radiators for resident safety and the provision of new assisted bathrooms, additional communal areas and more storage space. A new boiler system has been installed, including a water treatment centre to ensure against any risk from Legionella. An extension is being built at the rear of the home, which will take up part of the garden space. Upon completion of the work, the remaining garden will be landscaped to provide an attractive resource for residents. Mr Glanville says that every consideration is being given to resident safety during this time of transition and noise levels are being kept to a minimum. The laundry is sited on the lower ground floor and a member of staff is dedicated to managing the personal laundry for residents. Considerable improvements are taking place as the laundry is being refurbished and enlarged. New flooring has been laid which is easy to keep clean and there will be hand-washing facilities available for staff. Suitable facilities and procedures are in place in respect of the disposal of clinical waste. Hygienic hand gel is available at various points around the home and is used to help minimise the possible spread of infection. Storage facilities, including those for continence products, are currently being improved. Residents say they are satisfied with the laundry service and standard of cleanliness within the home. The domestic staff are to be congratulated for the level of cleanliness achieved in the home, in spite of all the difficulties created by the building work and the refurbishment currently in progress. DS0000032192.V317075.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to Windsor Court. The numbers and skill mix of staff are sufficient to meet the current needs of residents. Windsor Court is working to achieve the minimum ratio of 50 trained members of care staff at NVQ level 2, to help ensure residents are in safe hands. Recruitment practice is mush better, but minor improvements are still needed to ensure the protection of residents from the employment of potentially unsuitable staff. The home acknowledges the importance of staff training and is taking steps to ensure that staff are well trained and competent to do their jobs. EVIDENCE: Examination of the staff rota, discussion with residents, Mrs Seeborun and staff, as well as observation throughout the inspection, demonstrates a sufficient number and skill mix of staff to meet the current needs of the 40 residents accommodated. Mrs Seeborun says the number of residents with high or medium dependency needs has fallen at the present time, but she is keeping staffing levels constantly under review. DS0000032192.V317075.R01.S.doc Version 5.2 Page 22 On the day of inspection, eight care assistants were on duty in the morning and six care assistants during the afternoon and evening. From 7.45 p.m. until 8 a.m. there are three wakeful night care staff on duty. In addition, at least one member of the management team is on duty each day and available on call at all other times. The home also employs support staff, such as chefs, kitchen and dining staff, housekeeping, domestic, laundry and maintenance staff. Mrs Seeborun has introduced a “Key Worker” system, meaning that care staff each have special responsibility for a small number of residents and get to know them well. Residents were very complimentary in their comments about staff. The staff are very good. They always do their best for me, you cant ask for more than that. The staff are excellent. They work hard and have difficult jobs to do, but they always seem cheerful. The staff are kind to me and very helpful. Nothing is too much trouble. They are keen to help whenever required. I think the staff are excellent, I cannot praise them enough. The home is working to achieve the target of at least 50 trained members of care staff with National Vocational Qualification (NVQ) level 2, to ensure residents at Windsor Court are in safe hands. The home employs twenty care staff and three of these are currently studying for NVQ level 2. Five staff have attained NVQ level 3 and two more are just commencing NVQ level 3. Mrs Seeborun is hoping to encourage further staff to undertake NVQ training. The records of two recently employed staff members were examined and found to be greatly improved since the last inspection. They contain most of the essential information including an application form, an enhanced Criminal Records Bureau disclosure, and evidence of identity and of induction training. An equal opportunities policy underpins the employment practice of the home. The home must ensure that two written references are obtained. On one file a verbal reference had been given and not followed up with a written reference. Care must also be taken to ensure that a full employment history is taken, with any gaps explained. Mrs Seeborun says that when she took up her appointment as manager, she acknowledged the need for improvements to staff training as a means of improving the standard of care provided and ensuring residents safety. Improvements have been made and all new staff receive induction training. This includes a short introduction to the home followed by a more detailed induction, which will now be based on the Skills for Care Common Induction Standards, to ensure staff have the skills and knowledge necessary to fulfil their roles within the home. An audit of staff training has been carried out and an overview document produced which clearly identifies the training achieved by all staff in the home DS0000032192.V317075.R01.S.doc Version 5.2 Page 23 and where further input is needed. Further training is being arranged to ensure all staff receive appropriate training in moving and handling, fire safety, first aid, Protection of Vulnerable Adults, basic food hygiene, infection control and health and safety. It is hoped that all staff will have completed essential and mandatory training by the end of March 2007. Training in dementia awareness might also be helpful, as some staff commented that a number of residents have short-term memory loss and are confused. Copies of training certificates are being retained to provide evidence that staff receive a minimum of three paid days training per year. DS0000032192.V317075.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Windsor Court. Mrs Seeborun has not been in post very long, but already demonstrates a good knowledge of the operation of the care home and the needs of its residents. Windsor Court carries out regular audits to review its performance. The home has implemented a quality assurance system to ensure that residents remain satisfied with all aspects of the home. With the exception of the personal allowances of a few residents, the home does not become involved with residents’ finances. The premises and equipment are properly maintained and subject to ongoing improvements to ensure the comfort and safety of all in the home. DS0000032192.V317075.R01.S.doc Version 5.2 Page 25 EVIDENCE: Mrs Seeborun was registered with the Commission on 5th November 2006 and it is clear from this inspection that she has worked hard to bring about a number of changes throughout the home. Mrs Seeborun has started dealing with the issues identified in previous inspection reports, including the implementation of new formats for pre-admission assessment and care planning, improvements in recruitment procedure and the formal supervision process for staff. Mrs Seeborun says she is receiving good support from the registered provider, Lyndale Healthcare Limited, as well as from her management team, (Deputy Head of Care and Assistant Head of Care) residents and staff in the home. Residents commented, The new manager is very good. She is easy to talk to. I like the new person in charge. She seems friendly and approachable. She is getting things done.” Staff commented, “I like working here. We have a good staff team and good management.” “I think there have been a number of improvements in recent months. Everything is starting to settle down now the new manager is in post.” Mrs Seeborun says that Quality Assurance questionnaires have very recently been distributed to residents to obtain their views about the home, but no responses have yet been received. Plans are in hand to send out similar questionnaires to staff, relatives and other visitors to the home. Responses will then be collated and it is hoped to view these at the next inspection. Mrs Seeborun says she intends to reinstate an improved version of the Information File, which used to be on view to residents and visitors in the entrance hall. This will provide a copy of the Statement of Purpose and Service User Guide, details about quality assurance surveys, the complaints procedure, advocacy services, the activities programme and sample menus etc. Mrs Seeborun has commenced carrying out regular audits within the home e.g. medication and accident analysis. She is also currently reviewing policies and procedures to ensure best practice. A Residents Meeting was held in September 2006 and the issues raised have all been dealt with satisfactorily. For example, residents asked if the home could provide daily newspapers. Newspapers are now made available in the lounge every morning, in addition to those ordered individually by residents for their personal use. Regular staff meetings are also held so that staff may voice their views and share information. DS0000032192.V317075.R01.S.doc Version 5.2 Page 26 Several residents felt they would like to have more regular updates about progress with the refurbishment. For example, I wish I knew more about what was going on with the building work. Staff say the new bathrooms are nearly finished but it would be nice to be told this officially. I wish they would keep us more informed about progress with the alterations. Some residents found the work that rather noisy, but most were pragmatic about this and felt the end result would be Well worth waiting for. Mrs Seeborun says that, wherever possible, it is the policy of the home not to have any involvement in the personal finances of residents. Therefore those who are unable to handle their own affairs, or choose not to, have a relative or other representative to deal with their finances etc. The home pays for services such as chiropody and hairdressing and this amount is then invoiced to residents, relatives or representatives for payment each month. The home does look after small amounts of money for seven residents. This is held securely and a record kept of all income and expenditure. This was checked for one resident during the inspection and found to be in order. From touring the premises, looking at records and discussions with staff and residents, it is evident that measures are in place to promote the health and safety of residents, e.g. equipment, such as the lift and stairlift, hoists and portable electrical appliances are regularly serviced and maintained. All substances that could be potentially hazardous to health are handled and stored safely. Staff have received moving and handling training and further training is being planned, e.g., first aid. Mr Glanville reports that he has regular meetings with the builders on site to ensure the safety of residents during the current refurbishment and improvement programme. Mr Glanville says it is intended to fit guards to all radiators as part of the refurbishment and completion of this task is being made an early priority. At the last inspection it was noted that a number of bedrooms did not have a bedside or overbed light, creating difficulties for some residents at night. This has now been rectified. Examination of the fire records shows that appropriate procedures are in place to ensure the safety of residents and staff. Regular maintenance of the fire warning system, emergency lighting and fire fighting equipment is arranged. Routine checks are carried out at appropriate intervals and staff confirm this. Staff fire training, including induction training for new staff, is taking place and fire drills are arranged so that staff are fully aware of the action to take in the event of a fire. DS0000032192.V317075.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 DS0000032192.V317075.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12(1)(4) and 15(1) Requirement It is a requirement that all aspects of each resident s health, personal and social care needs must be recorded, including any psychological, social, cultural and religious needs. Care plans must make clear how these needs are to be met. 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. (Previous timescales of 31/12/05, 28/02/06 and 30/09/06 not fully met). It is a requirement that all parts of the home are kept reasonably decorated. (Work now in progress.) It is a requirement that suitable provision is made for storage. (Work now in progress.) The registered person must not employ staff to work with residents until satisfactory checks have been carried out. (Previous timescales of 28/02/06 and 31/07/06 not fully met). DS0000032192.V317075.R01.S.doc Timescale for action 01/05/07 2. OP18 13(6) 01/05/07 3 OP19 23(2)(d) 30/06/07 4 5 OP26 OP29 23(2)(l) 19(1) 30/06/07 01/04/07 Version 5.2 Page 29 6 OP30 18(1) The staff training and development programme must be completed, to ensure staff have the training necessary to carry out their work. 01/05/07 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 OP12 OP12 Good Practice Recommendations It is recommended that materials more suited to age and ability of participants be made available to the residents’ art group. It is recommended that, where possible, further information about each residents background, social history, previous hobbies and interests etc. is recorded, to ensure that the activities on offer at Windsor Court will be meeting the individual needs, preferences and expectations of residents. It is recommended that steps be taken to ensure that food remains hot when being transported from the kitchen to other areas of the home. Residents’ wishes regarding greater choice of menu should also be addressed as soon as possible. It is recommended that a minimum of 50 of care staff achieve NVQ level 2 training. It is recommended that, as refurbishment takes place, the guarding of radiators be made an early priority, to ensure resident safety. (Work now in progress.) Repeated 3 OP15 4 5 OP28 OP38 DS0000032192.V317075.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000032192.V317075.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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