CARE HOMES FOR OLDER PEOPLE
Windsor Court Care Home Bartholomew Avenue Goole East Yorkshire DN14 6YN Lead Inspector
Mrs Wendy Dixon Unannounced Inspection 11th November 2005 10:30 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 Care Home DS0000000962.V260986.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 Care Home DS0000000962.V260986.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Windsor Court Care Home Address Bartholomew Avenue Goole East Yorkshire DN14 6YN 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) 01405 763749 01405 765590 windsorcourt@highfield-care.com Southern Cross Care Homes No 3 Limited *** Post Vacant *** Care Home 77 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (52), of places Physical disability over 65 years of age (52) Windsor Court Care Home DS0000000962.V260986.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To admit one named service user with Dementia who is under 65 years of age. 24th May 2005 Date of last inspection Brief Description of the Service: Windsor Court is a modern purpose built care home situated close to Goole town centre. The home has two floors and a safe courtyard garden. There is a local health centre a short distance from the home. The home offers residential care on the ground floor (Balmoral) and care for people with dementia in a separate unit on the second floor (Buckingham). Adjacent to this is a unit for people with higher dependency needs (Sandringham). Windsor Court Care Home DS0000000962.V260986.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report relates to an unannounced inspection that took place on Friday 11th November 2005.The inspection lasted 4.0 hours (10.30am to 2.30pm) and involved 2 inspectors. There were 75 service users resident in the home, all receiving personal care. The inspection focused on a number of key standards, the areas of concern identified at the last inspection and issues raised in a complaint received by the Commission for Social Care Inspection. An inspection of the premises took place, including a number of bedrooms, the homes bathrooms and lounges. The care records of five service users were examined in detail and where possible these service users were spoken with about the care they receive. A number of staff was spoken to during the course of the inspection and the homes acting manager. The acting managers has been in post for 9 months and has made a number of changes, recruited new staff, reviewed routines and care practices and carried out a satisfaction survey with relatives and service users. The care service has improved and the home now provides service users with a comfortable and safe home. What the service does well:
Windsor Court provides a good standard of care. The home had a calm and pleasant atmosphere and the building is purpose built, access is good throughout so service users can use the lounges, dining rooms and safe enclosed gardens. Service users were able to spend their day as they wished. Service users were in their rooms watching TV or reading, some were in one of the homes lounges chatting and socialising with other service users, a bar/pub area has been opened which was very authentic looking and one service users was celebrating his birthday with other service users in the home. Service users were relaxed and happy to chat about life in the home and recent events. Staff were well informed about service users health and personal care needs and were observed talking and assisting service users in a kind friendly and
Windsor Court Care Home DS0000000962.V260986.R01.S.doc Version 5.0 Page 6 professional manner. All new staff receive good training when they start work in the home and training for all staff is well organised and up to date. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Windsor Court Care Home DS0000000962.V260986.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 Care Home DS0000000962.V260986.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): 3 Pre admission assessments contain good information about the health and personal care needs of service users to help ensure the home can meet their needs. EVIDENCE: The pre admission assessments inspected contained detailed information about service users care needs. Information was clearly documented and discussed with the team leader of the unit the service user was to move into before they were admitted to ensure all their needs could be met. Information had been sought from service users relatives and other professionals such as care managers and doctors. If the admission was at very short notice and a member of staff could not meet/visit the service user an assessment was sought from other health professionals before a decision to admit them to the home was made.
Windsor Court Care Home DS0000000962.V260986.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Some service users care plans do not reflect service users current care needs and are in need of updating EVIDENCE: 5 service users care plans were inspected. These contained clear information about service users health and personal care needs and in most cases what staff needed to do to meet them. However one care plan had not been up fully updated. The service user had particularly challenging behaviour and the way she was to be cared for had substantially changed, these changes were not in the care plan or risk assessments. Any confusion about the service users care needs could have triggered a serious incident. There were examples of good practise where medical intervention had been sought speedily to ensure service users got the care they needed. Medication records were accurate and completed as per the homes policy however not all records inspected had photographs of service users attached to assist with identification.
Windsor Court Care Home DS0000000962.V260986.R01.S.doc Version 5.0 Page 10 Staff were observed speaking to service users in a kind, friendly and respectful manner. All service users were well dressed, men wall shaved and ladies with smart hair. All service users have single rooms and bathrooms and toilets have locks with privacy signage. Windsor Court Care Home DS0000000962.V260986.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 and 15 Service users can choose to spend their days as they wish, and there is a range of activities service users can participate in if they want to. EVIDENCE: The home had a relaxed atmosphere. Service users were at different points in their morning routine, some in their rooms listening to the radio and reading the newspapers. Others seeing family and friends or watching television showing that support for service users is individual to them and not based on fixed routines. The home has two part time activities organisers who spend time with service users on an individual basis and as a group. The meal served during the inspection was lunch; this was nicely presented and enjoyed by the service users who commented generally the food was very good at the home. Service users can either eat in their rooms or in the homes dining room. There was a flow of visitors to the home during the inspection that were made to feel welcome and able to see the service user in their room or the homes lounge.
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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 Services users and families are aware of how to complain and polices are place to deal with any abuse should it occur. EVIDENCE: One complaint has been received since the last inspection. This has been investigated by the registered provider and appropriate action taken. The home has a clear complaints procedure, which is included in the information given to service users on admission that informs service users and their families how to complain if they are unhappy with the care or service at the home. The Home has policies regarding abuse copies of which were kept in the home and made available to staff members. Windsor Court Care Home DS0000000962.V260986.R01.S.doc Version 5.0 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 the following standard(s): 19 and 26 The home offers good quality accommodation to all its service users and is a clean, comfortable and safe place for service users to live. EVIDENCE: Access is very good throughout the building. Decoration and maintenance is to a high standard. The home has secure well-maintained gardens for service users to enjoy. Service users rooms are very much their own and personalised with pictures, photographs and small items of furniture they have brought from home. The home was clean and fresh smelling t and gloves and aprons were in good supply, to help prevent the spread of infection. Windsor Court Care Home DS0000000962.V260986.R01.S.doc Version 5.0 Page 14 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 There are enough well trained staff to meet service users needs. EVIDENCE: The numbers of staff employed at the home has increased. 6 Care staff are now on duty at night 2 on each unit. 10 During the day 4 in Balmoral, 2 in Buckingham and 3 in Sandringham one care assistant is then allocated on a day-to-day basis depending on service users needs. 3 Staff training records were inspected these were up to date. Staff had received, moving and handling, fire, first aid, dementia and prevention of abuse training. The manager had a good system that clearly showed when training needed to be renewed and this was discussed with staff during supervision. One new member of staffs employment file was inspected. They had received thorough induction training and all the necessary checks and references were in place to ensure service were cared for by people suitable to do so. Windsor Court Care Home DS0000000962.V260986.R01.S.doc Version 5.0 Page 15 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): 32,33,35,36 and 38 The home is well managed and provides a safe place for service users to live and staff to work. EVIDENCE: The manager has now been in post for nine months and during that time the care of service users has improved greatly. Proper systems are now in place to ensure staff are properly trained and supervised. Service users and relatives are asked if they are satisfied with the care and any comments are listened to and changes made if needed. The manager is their on a daily basis meets service users, relatives and is aware of all their concerns and issues and deals with them promptly. The home is well maintained there are no outstanding issues with the environmental health or fire safety officer.
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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 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 4 3 X 3 3 X 3 Windsor Court Care Home DS0000000962.V260986.R01.S.doc Version 5.0 Page 17 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 OP8OP7 Regulation 15 2 b Requirement The responsible individual must ensure that : that service users care plans and risk assessments are regularly reviewed and fully reflect their care needs. All service users must have a recent photograph on the front of the administration sheet to help identify them. Timescale for action 01/02/06 2. OP9 13 2 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Windsor Court Care Home DS0000000962.V260986.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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