Inspection on 10/08/05 for Windsor Court Residential Home

This inspection was carried out on 10th August 2005.

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

The inspector 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 Residential Home 28/10/08

Windsor Court Residential Home 30/10/06

Windsor Court Residential Home 07/11/05

Windsor Court Residential Home 17/03/05

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

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Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Windsor Court 44-50 Windsor Road Oxbridge Road Stockton-on-Tees TS18 4DZ Lead Inspector Katherine Acheson Unannounced 10 August 2005 9:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Windsor Court Address 44-50 Windsor Road Oxbridge Road Stockton-on-Tees TS18 4DZ 01642 618276 01642 618276 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Oxbridge Care Limited Care home only 32 Category(ies) of Old People - OP - 32 registration, with number of places Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/03/05 Brief Description of the Service: Windsor Court is registered to provide personal care to a maximum number of thirty two older people. The home is situated in a quiet residential road in the Oxbridge area of Stockton on Tees, and is close to shops, park and other local amenities. Internally the home offers two spacious lounge areas and a separate dining room facility for communal use. The thirty two bedrooms are all single in nature, five of which have ensuite facilities comprising of a sink and toilet. All bedrooms in the home environment meet size requirements of National Minimum Standards. To the rear of the home there is an enclosed garden area and parking facilities for staff and visitors. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days and lasted for almost twelve hours. Two Inspectors were present throughout the inspection process. Prior to inspection the Commission for Social Care Inspection received two complaints in respect of this service and as such the complaints were investigated as part of the inspection process. Elements of the complaint have not been directly highlighted, however those elements of the complaint that following investigation were highlighted as requiring addressing, have been mentioned in the main body of the report. A separate complaints investigation report has been completed. Five residents, five staff, The Manager and the Registered Providers were interviewed and spoken to. Numerous records including duty rotas, policies/procedures, care plans and staff records were examined. What the service does well: What has improved since the last inspection? This was a first visit to the home for the Inspectors and as such makes it difficult to assess what has improved since last inspection. The Inspectors were made to feel extremely welcome by staff and residents throughout the inspection process. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 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 B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 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 standard(s) 2, 3, 6 Assessments of needs are carried out to ensure that the home can meet the needs of the individual person. Residents/representatives are provided with a contract, which enables them to be informed of the terms and conditions of their stay. EVIDENCE: The Manager said that staff at the home do not carry out their own preadmission assessment of residents, however, an assessment is carried out by a Social Worker or health care professional, and the home receive a copy of this assessment before the person is admitted to the home. Records were available on files examined during this inspection to confirm that this is the case. It was highlighted at the last inspection that the home’s statement of terms and conditions/contract should be updated to include room to be occupied, contain current information and be dated. Residents files examined during this inspection confirmed that this had been addressed. The home does not provide intermediate care. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 The home provides a high standard of care, which ensures that the health personal and social care needs of residents are met. The home’s medication policy, systems, training arrangements and practices that are currently in operation in the home do not ensure safe practice. EVIDENCE: Four residents plans of care were examined during this inspection. Files examined were found to be informative, well presented and individual to the needs of the resident. Files examined contained a record of visits carried out by chiropodists, G.P’s, opticians and other health care professionals. They had been updated on a monthly basis and contained evidence of resident and family involvement. The current system in the home is that all needs and medical problems are highlighted collectively and evaluated as one. Care plans could be further enhanced by highlighting each problem separately, identify goal and describe action that is required by staff/resident to meet the goal and manage the problem. Care plans should include limitations of the residents and assistance that is required. Care plans would benefit from being evaluated individually. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 Page 10 Five residents were spoken to during the inspection, all of who spoke highly about the home and the care that that they received. One resident said, “I feel secure here, I like it, this is a really good place to be”, another said, “It’s very good here I can’t complain”. Residents spoken to said that they are treated with respect and provided with dignity. The home has a policy/procedure in respect of medication, however this requires further development to include all of the required elements. Records were available to confirm that the home have appropriate systems in place to record medication coming into the home and medication being returned to pharmacy. An audit trail of the medication coming into the home and medication being returned to pharmacy was carried out by the Inspectors and high lighted a shortfall in liquid medication, an immediate requirement was left in the home in respect of this. Following interviews with staff it became evident that secondary dispensing of medication was occurring. Medication is being dispensed by Senior Care Staff into pots and other care staff on occasions then administer the medication to residents. The Manager was informed during this inspection that this practice must stop immediately. The Manager was also informed that prescribed creams and ointments must only be applied by those staff who are trained to do so. It was highlighted at the last inspection that staff who administer medication must have received appropriate, competence based training, which must be certificated. Records were available to confirm that staff at the home had carried out distance learning training in respect of medication, however this had not been marked or competence assessed and as such was not certificated. The Commission for social Care Inspection will make a further visit to the home to ensure that action has been taken to address the above areas. One resident spoken to during the inspection said that she would like to have her medication earlier on a night, this was pointed out to the Manager at the time of the inspection who said that she would take action to address this. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14 Resident’s lives are enhanced by the social activities provided by the home and by the welcome it extends to visitors. EVIDENCE: The Manager said that the home employs an Activity Co-ordinator for approximately eight hours a week and that at other times care staff organise activities for residents. Residents spoken to during the inspection spoke of karaoke, crosswords, sing a longs and regular walks to the local park. Recent events at the home have included a summer barbeque, quiz night, pie and pea night and a trip out on the Teesside Princess. One resident spoken to during the inspection said, “The barbeque was wonderful all of our relatives came in, it was a proper get together”. Another resident said how much she had enjoyed the trip out on the Teesside princess. One resident said, “I am happy with the activities there isn’t a lot but enough”. Residents interviewed spoke of freedom of choice and the ability to maintain control over their lives. Indirect observation showed that relationships between staff and residents were very good, the atmosphere within the home was relaxed and staff were respectful when attending to residents. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 Page 12 The Manager said that visitors are welcome in the home up until 9pm, however, later visiting can be arranged if required. The Manager said that two residents go to church with their family on a weekly basis and that there are regular visiting clergy to the home. Although standard 15 was not inspected one resident interviewed during the inspection said that at this moment in time that she is not enjoying the food that the home is providing. This was pointed out to the Manager at the time of the inspection who said that she would meet with the resident to discuss an individual diet plan. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 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 standard(s) 16 The home has an effective complaints procedure, which enables residents to make any complaints they feel necessary. EVIDENCE: The home has a clear complaints procedure, details of which are also available in the statement of purpose and service user guide. Residents interviewed during the inspection said that the Manager and staff at the home are approachable and if they felt the need to complain then they would do so. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 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 standard(s) EVIDENCE: The above standards were not inspected. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 Appropriate numbers of staff are on duty to meet the current needs of the residents, however, residents are not protected by the home’s recruitment policy and practices. EVIDENCE: Duty rotas examined confirmed that the home are working with staffing levels agreed by the Commission for Social Care Inspection for the current resident occupancy levels in the home. Residents interviewed during the inspection said that they felt that there was sufficient care staff on duty and that when they rang for assistance staff were readily available to help. One resident said, “Staff are there day and night, we are well looked after” another said, “ Staff are very polite” another said, “I’m fairly happy at the home, some staff are better than others, staff have a laugh with you” It was highlighted at the last inspection in March 2005 that the home’s recruitment policy/procedure required further development, staff files must be updated to include a recent photograph and that all staff must receive an appropriate Criminal Record Bureau Check prior to the commencement of employment. Examination of records highlighted that action had not been taken to address outstanding requirements. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 Page 16 Four staff files were examined at random during this inspection, two of which were observed to contain a recent photograph of the staff member, two of which didn’t. Records examined highlighted that staff are commencing work at the home prior to the receipt of a satisfactory POVA first/Criminal record Bureau Check. An immediate requirement was left at the home in respect of this and will be followed up by the Commission for Social Care Inspection. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The home ensures that the health and safety of residents is safeguarded and protected EVIDENCE: The home operates a rolling programme of servicing appliances and equipment. Records examined at random confirmed that the homes fire extinguishers, fire alarm and gas boilers are serviced on a regular basis. The Manager said that all windows on the first floor of the home are restricted to ensure safety of residents. Mandatory training has recently been provided to staff working at the home, certificates were available to confirm that this is the case. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 Page 18 Standard 36 was not inspected in full, however, it was highlighted at the last inspection that the home’s induction process must be reviewed. The Manager informed the inspector that this has been carried out and provided an updated copy of the induction for inspection. Examination of this document highlighted that further development is still required. A discussion took place with the Manager in respect of this. Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 3 Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 Page 20 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 OP9 Regulation 13 Requirement The homes medication policy must be developed further in respect of reciept, storage, administration and disposal of routine and controlled medication Secondary dispensing of medication must stop Prescribed creams and ointments must only be applied by those staff who are trained to do so The Registered Providers/Manager must ensure that staff who administer medication receive appropriate, competence based training, which should be certificated The Manager must take immediate action to address the shortfall of liquid medication The homes policy/procedure in respect of staff recruitment must be reviewed and updated The Manager/ Registered providers must ensure that all staff receive a satisfactory POVA first/ Criminal Record Bureau Check prior to the commencement of employment Staff files must be updated to Timescale for action 30th September 2005 2. OP9 13 Immediate 3. OP9 13 Immediate 4. 5. 6. OP9 OP29 OP29 13 19 13, 19 Immediate 30th September 2005 Immediate 7. OP29 17, 19 30th Page 21 Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 8. OP36 18 include a recent photograph of the staff member The homes induction requires further development September 2005 30th September 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Care plans should be developed further to ensure that each problem/medical condition is highlighted separately. Care plans should clearly identify the goal and action/care needed to meet the goal and manage the problem. Care plans should include limitations of residents and assistance required 2. OP28 Care plans would benefit from being individually evaluated. The Manager should continue with her action plan in which to achieve 50 of care staff qualified to NVQ level 2 in care Windsor Court B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Unit B, Advance St Marks Court Teesdale Stockton-on-Tees TS17 6QX 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 B51-B01 S60372 Windsor Ct V243521 100805 Stage 4.doc Version 1.40 Page 23 - 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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