Inspection on 27/06/06 for Windsor Court Care Home

This inspection was carried out on 27th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Windsor Court Care Home 11/11/05

Windsor Court Care Home 24/05/05

Windsor Court Care Home 28/09/04

Windsor Court Care Home 30/07/04

Windsor Court Care Home 06/05/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Windsor Court Care Home Bartholomew Avenue Goole East Yorkshire DN14 6YN Lead Inspector Ms Anne-Marie Foster Key Unannounced Inspection 27th June 2006 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 Care Home DS0000000962.V302116.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. Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 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 Mrs Margaret Dolores Barton 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.V302116.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one named service user with Dementia who is under 65 years of age. 11th November 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 are pleasant, well maintained gardens. There is a local health centre a short distance from the home. The home offers residential care in three units: the ground floor (Balmoral unit) provides residential care. People with dementia are cared for in a unit on the second floor (Buckingham), and, adjacent to this is a unit for people with higher dependency needs (Sandringham). A passenger lift is available. Fees range from £286.00 to £430.00 per week.(Information provided May 2006) Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site visit. The registered manager and deputy manager were present and able to assist the inspector. Time was spent talking to staff and service users and one visitor, and seven care files were inspected. Observations of general activity took place, and communal areas and service users rooms were inspected. Staff records and medication records were looked at along with the homes policies and procedures documentation. As part of the inspection, surveys were sent out to 10 relatives of service users, and one reply was received. Information was also obtained via a pre-inspection questionnaire that was sent to the registered manager of the home. What the service does well: What has improved since the last inspection? Good progress has been made with care plans, including a new format. The seven care plans inspected were excellent generally, and were reviewed regularly at least once per month or more frequently if necessary. Medication records now have a photograph of the service user on them, which was identified as a problem at the last inspection; this will help staff to identify residents and reduce any risk of error. Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 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 Care Home DS0000000962.V302116.R01.S.doc Version 5.2 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.V302116.R01.S.doc Version 5.2 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 and 6 Quality in this outcome area is excellent. This judgement has been made using available evidence during a visit to this service. Service users are admitted only after a full assessment to ensure that their needs can be met by the home. EVIDENCE: Seven care files were inspected and all of these included excellent pre admission assessments, the registered manager and deputy manager arrange to assess a prospective service user and liaise with relatives and/ or other relevant allied professionals; this ensures that no service user is accepted into the home if their needs cannot be met. One service user staying for intermediate care only, had a thorough assessment of needs prior to admission, which assists staff in the planning of the most appropriate care that would enable a return to home. Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are met and dignity and privacy is maintained, though some further improvements could be made to care plans. EVIDENCE: Good progress has been made since the last inspection with care plans, the service users needs are set out well generally, and the care plans are reviewed regularly, this will help to ensure that health personal and social needs are met. Two care plans showed that the service users had a steady weight loss, and whilst the weight was recorded regularly and staff were offering the appropriate care, the plans did not accurately reflect this, meaning it was difficult to assess what action they would take next in order to prevent further weight loss. The medication administration records were inspected, and the method for ordering /storing and return of medication was found to be satisfactory, the staff are aware of the homes medication policy, and each medicine administration record has a photograph of the service user attached, all of which contributes to the service user being protected by a safe medication system. Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 Page 10 Staff were observed whilst they worked during the day, and were seen to be calm, efficient and respectful in their manner. Staff used the preferred term of address, and assisted appropriately when necessary, allowing the service user’s right to dignity and privacy to be upheld. Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy a variety of activities and can exercise choice in their daily life. EVIDENCE: The home employs two activities organisers, and there are a variety of activities available, daily life is flexible, meaning that service users can choose how they spend their day. On the day of the inspection the organiser was taking service users out in the minibus for a choir trip this included the residents from each of the three units, and the choir group are soon to release their own CD. Service users interests are recorded in the care plans and this helps staff to plan appropriate activities. Contact is made with the local community regularly and visitors can come and go freely as the service user wishes, meaning that they are able to exercise control of their life. One relative was “very pleased with the home and with how the staff have helped mum settle in, and I can visit anytime during the day”. The home has its own ‘pub’ .This is a room decorated in the style of a public house with its own bar and dart board, bar tables and stools, like the 1950’s lounge, it is an area enjoyed by the service users who can use the facilities as they please and therefore exercise choices in their daily routine. The registered manager is also planning to open a shop and ice cream parlour for the service users and their family and Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 Page 12 friends. This will offer a further dimension to the choices that service users have. The lunchtime meal was observed; an appetising roast dinner, which was thoroughly enjoyed, and service users reported that the “food is very good”. The meal was unhurried with service users being given sufficient time to eat, meaning the meal was an enjoyable part of the day. Whilst the dining rooms are light and pleasant, one of the dining rooms upstairs looked slightly cramped, and although all of the service users were able to sit down together, this could compromise comfort at mealtimes. Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a clear complaints policy, and so are generally safeguarded by the homes policy and practices. EVIDENCE: There is a clear complaints policy available in the hallway, which offers information on how to make a complaint. Complaints made and the actions taken are recorded, meaning service users and their relatives can be confident that their complaints will be acted upon. Three Service users asked said that they felt confident that any complaint they had would be listened to and acted upon. One said “ I would have no hesitation in speaking to the manager if I had a complaint. Two staff members said that they knew the registered manager would act upon any complaint they had. There have been no recent complaints about the home since the last inspection. Staff attend training about abuse awareness and this is provided every six months, it includes videos, written information and the manager was about to cascade a presentation that she had recently attended, ensuring staff were knowledgeable about the protection of the vulnerable adult. Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a well maintained, clean, and hygienic home. EVIDENCE: The home is modern and purpose built, and so the layout is suitable for elderly service users. Grounds are kept very tidy and there is a safe inner courtyard, which is accessible and pleasant, this is of benefit to the service users. There is a routine programme of maintenance, and a maintenance man is employed who works to a high standard, meaning that the home is in a good state of repair. There is a good team of domestic staff including a housekeeper, 3 laundry assistants and 6 domestics, who all work to a high standard, ensuring the home is kept clean. The laundry assistants confirm that carers adhere to the homes policies for soiled laundry, and so good hygiene standards are maintained. Staff report that the supply of aprons, gloves, hand disinfectant is plentiful, helping towards the prevention of spread of infection. Service users have the door to their room personalised, each door is painted a different Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 Page 15 colour and has an individual brass doorknocker meaning that the room could be easier to identify. Call bells were placed within easy reach for the service users and calls were answered promptly, enabling their needs to be met. There are a selection of areas in which to spend some time, with several day rooms, a quiet room, and an activities room offering a variety of choice to the service user. Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 27,28,29,30. Quality in this area is adequate. This judgement has been made using available evidence including a visit to this service. Care is given by an experienced, enthusiastic and knowledgeable staff team, however service users would benefit further from an improvement to the homes recruitment policy, and by having more of the staff qualified to NVQ level 2 in care certificate. EVIDENCE: The staff that were observed and spoken with on the day of the inspection all enjoyed their work at the home, and the registered manager has an organised training programme in place with regular in house and external events taking place, this means that staff are very knowledgeable about good care practices. Service users were very complimentary about staff “they work hard and are kind” “they show respect”. Less than 50 of staff are qualified to NVQ2 however, although 4 staff are currently on the course and 10 are waiting to start, gaining the NVQ2 training will increase the skill mix of staff and service users will benefit from this. Whilst the home has a good recruitment policy, out of four staff files that were inspected, two files did not show that the home had obtained the necessary two written references from previous employers, these were currently being ‘chased up’ but the new employees had already started to work; this could compromise the other good work in this area. Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 Page 17 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): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users benefit from having an experienced manager in charge, and the home is run in their best interests. EVIDENCE: The manager is qualified and competent, and has an approachable style of leadership, meaning the service users best interests are safeguarded. Service users report that they find the manager “kind and approachable”, which means they feel safe. The manager has a comprehensive quality assurance system and regularly seeks the views of the service users and their families about issues in the home; a recent extra questionnaire to find out what food service users would like to see on the menu met with a good response, showing that people were able to voice their opinions. Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 Page 18 Records show that staff are well supervised, and the manager and deputy manage to supervise staff for more than 6 times per year, this will help to ensure staff are aware of good practice and understand the homes policies. The registered manager was able to provide the inspector with the necessary policies and procedures that support good compliance with health and safety regulations, and this shows that the health and safety of staff and service users is promoted. Accidents are recorded appropriately and safety procedures are followed. A requirement from the fire safety inspection of May 2005,was outstanding as the home were waiting for quotations for the work, whilst this still has not been complied with the manager has just obtained approval for the work to go ahead, this includes strips to fire safety doors and will further protect the service users and staff. Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 Page 19 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 4 X X X 4 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 1 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 3 Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP28 Regulation 18 Requirement The registered manager must ensure that more than 50 of care staff have the NVQ2 in care certificate. The registered manager is required to obtain two written references before new employees start working at the home. Timescale for action 01/12/06 2. OP29 19 27/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP8 Good Practice Recommendations It is recommended that care plans set out in detail the actions that need to be taken by care staff to meet the needs of the service user. It is recommended that appropriate action is taken and recorded in response to nutritional screening care plans and weight loss records. Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 Page 21 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 © 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 Windsor Court Care Home DS0000000962.V302116.R01.S.doc Version 5.2 Page 22 - 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. 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