Inspection on 17/03/05 for Windsor Court Residential Home

Care Home For Older PeopleWindsor Court44 - 50 Windsor Road Oxbridge Road Stockton-on-Tees TS18 4DZAnnounced Inspection17th March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Windsor Court Address 44 - 50 Windsor Road, Oxbridge Road, Stockton-on-Tees, TS18 4DZ Email address pmughal@hotmail.com Name of registered provider(s)/company (if applicable) Oxbridge Care Limited Name of registered manager (if applicable) Mrs Valerie Smith Type of registration Care Home No. of places registered (if applicable) 32 Tel No: 01642 618276 Fax No: 01642 618276Category(ies) of registration, with (number of places) Old age, not falling within any other category (32) Registration number B510002013 Date first registered 28th July 2004 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 29th September 2004 YES NO 2/6/04 If Yes refer to Part CWindsor CourtPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 317th March 2005 09:30 am Jackie Herring Christine Moon NA NA NAID Code073890Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMr and Mrs Mughal ­ Registered ProvidersWindsor CourtPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementWindsor CourtPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Windsor Court. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Windsor CourtPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Windsor Court is a Care Home offering personal care for up to 32 older people. Dependency needs catered for are those ranging from low to high-dependency level of need. Windsor Court is not registered to provide nursing care. The home is situated in a quiet residential road in the Oxbridge area of Stockton on Tees. The 32 bedrooms are all single, 5 having en-suite facilities. There are two lounges for communal use, and a separate dining room. At the rear of the home is an enclosed, secluded garden, which can be accessed from the dining room and lounge, and this area offers pleasant space for residents to sit and relax, when weather permits. The home is located close to a local park, which is frequented by residents with staff escorts. The town shops are also close to the home.Windsor CourtPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection was an announced inspection and was completed in one inspection day. The inspectors were very warmly welcomed to Windsor Court by the proprietors and staff team. The inspection focused on the standards not assessed at the last unannounced inspection and also the outstanding requirement and recommendation, all three of which had been addressed. A number of service user and relative surveys had been returned; all stated extremely positive comments about the care provided within Windsor Court. Residents and their relatives were spoken to throughout the inspection and the comments received spoke very highly of the positive outcomes and experiences for individuals living within Windsor Court. They stated that this is the best, we could not ask for more; friendly, openness and approachability of the staff and owners; lovely staff, the owners are genuine caring people ­ could not ask for more. A large number of standards were inspected and in the main, met the required standard. Throughout the inspection there was regular discussion with the proprietors, the level of commitment, enthusiasm and desire to ensure that the required standards were met impressed the inspector who was involved in these discussions. A small number of the standards inspected were identified as needing further development; these included ensuring the recruitment and selection procedure was more robust and in keeping with the required standard and schedule; further development of the induction programme, developmental programme for staff promotion; more formal training in respect of administration of medicines and a more detailed and fuller review of the policies and procedure, which would benefit from more detail.Windsor CourtPage 6 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Windsor CourtPage 7 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The registered providers must ensure that the recruitment and selection procedures are in keeping with the required regulation and also Schedule 2 of the Care Homes Regulation 2000. The registered providers/manager should ensure that staff, who administer medication have received appropriate, competence based training, which should be certificated. The registered providers/manager must review the current induction and staff development/promotion systems. There should be evidence to ensure levels of competences are assessed and there is supporting documentation in place.119OP29Immediate213OP91 July 2005318OP361 July 2005Windsor CourtPage 8 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * The terms and conditions should specify the number of room to be occupied by individual residents and should be also be dated, ensuring that it contains current information. The registered providers/manager should ensure that a minimum of 50 of care workers achieve NVQ level 2 in care.1OP22OP28* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Windsor CourtPage 9 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES NO YES NO NO NO YES YES NO YES YES YES YES NO NO YES YES 5 4 0 NA NA YES YES 12 0 17/3/05 9.45 6.15Windsor CourtPage 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Windsor CourtPage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extrasYESHAIRDRESSING If yes, please state what the extras are: 3 Key findings/Evidence Standard met? A combined document was made available for examination during the inspection and contained the required information. A copy of the last inspection report was also included.Windsor CourtPage 12 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 2 Key findings/Evidence Standard met? The proprietor said that signed statements of terms and conditions were contained within the residents files. A random sample of files was examined during the inspection and it was confirmed that signed terms and conditions were available. These required some additional development to include the room number that the resident occupied and also the date that these were signed. Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? It was confirmed through discussion with the proprietor that a copy of the care managers assessment and care plan is always obtained prior to any new residents being admitted into Windsor Court. Three residents files were examined and they contained care managers assessments, care plans and reviews. It was also confirmed that staff at the home also carry out their own pre admission assessment. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? Windsor Court is a care home that provides personal care for older people. This was clearly demonstrated within the Statement of Purpose/Service Users Guide. Resident and relatives during discussion stated that Windsor Court was well able to meet their individual needs.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Through discussion with residents and relatives it was confirmed that they had visited the home prior to admission. Six-week reviews also took place to ensure suitability of home.Windsor CourtPage 13 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Windsor Court does not provide intermediate care.Windsor CourtPage 14 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 0 Key findings/Evidence Standard met? This standard was not examined during this inspection.Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence This standard was not examined during this inspection. X X Standard met? 0Windsor CourtPage 15 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? This standard was not fully examined during the inspection however it was identified that staff training in respect of administration of medicines needed to be developed more formally, with competences being assessed. It was also recommended that care workers who are responsible for the administration of medicines should obtain a recognised qualification. There was discussion with the proprietor about a twelve- week open learning module, which she is going to investigate further. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Through discussion with residents, relatives and staff, it was confirmed that the core values of care are understood and demonstrated at all times within Windsor Court. Residents spoke of their privacy and dignity needs being well respected, and personal care being carried out in the appropriate manner.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard was not examined during this inspection.Windsor CourtPage 16 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? This standard was not examined during this inspection.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? A number of visitors were in the home on the day of the inspection and they stated that they were able to visit at any time and that they were regular visitors to the home. Relatives spoke highly of the reception they received when they were visited and said that they were always made to feel very welcomed. During the inspection, relatives were observed to have lunch with their loved one. Relatives also spoke very positively of the recent pie and pea supper and also of the activities over the Christmas period, which also included relatives. Residents also spoke of being able to go with family members if they wanted to. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? This standard was not examined during this inspection.Windsor CourtPage 17 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This standard was not fully examined during this inspection, although the inspector did join residents for lunch, which was traditional home cooking. Alternative meal options were evidenced during this meal-time. Relatives were also observed to have lunch with their loved one during the inspection.Windsor CourtPage 18 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 7 7 0 0 0 0 100 3 Key findings/Evidence Standard met? Seven complaints were logged within the complaints book, all of which were informal concerns primarily about the quality of some of the food provision. In all cases, immediate action was taken and the situation was resolved. During the inspection, it was identified that the complaints procedure was in need of further development; this was attended to immediately by the provider, who produce a new procedure and updated the policy file and complaint procedure.Windsor CourtPage 19 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? During discussion with residents and relatives, it was confirmed that residents were able to participate in the civil process and had been given the relevant voting papers.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 13 Key findings/Evidence Standard met? The proprietors have implemented the No Secrets procedure since the last inspection, and this was dealt with very well, with the necessary action being taken. Staff during interview were able to talk about abuse and no secrets and a copy of the Teesswide Protocols and Guidance was available within the staff office. It was identified during the inspection, that the policy and procedure for abuse and the reporting of abuse was in need of further detail, this was addressed immediately during the inspection with the policy on abuse and the procedure for No Secrets being combined.Windsor CourtPage 20 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard was not examined during this inspection.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This standard was not examined during this inspection.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not examined during this inspection.Windsor CourtPage 21 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not examined during this inspection.Windsor CourtPage 22 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence This standard was not examined during this inspection. YES NO NO X X X X Standard met? 0 X XX X X XWindsor CourtPage 23 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? This standard was not examined during this inspection.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? This standard was not examined during this inspection.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? This standard was not examined during this inspection.Windsor CourtPage 24 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X Standard met? 3Windsor CourtPage 25 The duty rota was examined during the inspection and showed that there were three staff on duty throughout the day, one of which was a senior care worker and two staff on duty at night, again one of which was a senior. It was also confirmed that there is domestic, laundry and catering staff on duty seven days per week. The managers supernumerary hours are currently under discussion. It was also confirmed, that the proprietors are regularly in the home and will complete or assist with a number of tasks. The proprietors do complete a number of the administration duties required to run and operate the home. It was confirmed through discussion with residents, relatives and staff that there is sufficient staff to meet the needs of the residents and the staff were highly visible on the day of the inspection and were interacting extremely well with the residents. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 0 0 1 Key findings/Evidence Standard met? It was acknowledged during discussion with the proprietors that there has been difficulty achieving this standard due to staff turnover. It was however identified that there was a real commitment to training and steps are well underway for staff to achieve the required training. Currently, 50 of the care staff are underway with NVQ two or three in care.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 1 Key findings/Evidence Standard met? A random examination of staff files identified that there was the need for further development to ensure that robust and safe procedures were implemented and followed. Two of the staff files examined did not contain the appropriate CRB check, there was no up to date photograph of staff in place except the one on the copy of the staff members passport and written references were received after commencement of employment. Through discussion with the proprietor, it was agreed that they would take immediate action to address this situation. The recruitment and selection procedure was also in need of updating and development to ensure that Schedule 2 was being achieved.Windsor CourtPage 26 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? It was confirmed through discussion with the proprietor that all staff undertakes TOPPS induction training. This was recorded within the staff training records.Windsor CourtPage 27 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The registered manager has the appropriate qualification and experience. The inspector was made aware that the manager is leaving the home and they are in the process of recruiting a suitable replacement.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not examined during this inspection.Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? A number of quality assurance systems were evidenced during the inspection such as resident personal allowance audit, resident and staff meeting minutes, residents and relatives surveys that had been analysed and a reports produced, which were available for examination.Windsor CourtPage 28 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 3 Key findings/Evidence Standard met? A range of information was provided along with the pre inspection questionnaire, this included a letter from the providers accountants, which confirmed the financial viability of the home. Reference was however made to the current occupancy level of the home, which the providers are looking along with some ideas as how this will be addressed.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X3 Key findings/Evidence Standard met? A random sample of residents personal allowances were examined during the inspection and the system was found to be robust, with regular audits taking place.Windsor CourtPage 29 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? An examination of staff records and the induction programme took place during the inspection. During discussion with the proprietors it was identified that these records were in need of further development. The induction currently is more of an initial orientation checklist, which takes place over the course of one day. The programme for the training of senior care workers was also in need of development as it did not contain any narrative or discussion on level of competence or show the level of training the was put into place prior to any staff members being promoted. The proprietors were very specific that the training was phased, however it could not formally be evidenced in sufficient detail. The proprietor informed the Inspector that supervisions and appraisals take place as required and that these records are kept on a separate file, which was not evidenced during the Inspection. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? Records were appropriately stored within the home and the home is registered for data protection. A confidentiality statement was also contained within the staff files examined during the inspection.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? A random sample of maintenance records were examined during the inspection, including the water temperatures and weekly fire checks, these were all in order. A file containing all of the service agreements and servicing of equipment was also made available for examination and the records that were examined were all up to date. Mandatory training was evidenced both on the training file and also individual staff files. Training such as moving and handling and first aid is delivered once a year by an external training organisation, this is supplemented throughout the year with the use of in house training through videos.Windsor CourtPage 30 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorJackie HerringSignature Signature SignatureRegulation Manager Ken Pollard Date 5 April 2005Windsor CourtPage 31 Public reports It should be noted that all CSCI inspection reports are public documents.Windsor CourtPage 32 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 17 March 29005 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Providers comments and an action plan are available at the Area Office, where these have been submitted.Windsor CourtPage 33 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 19 April 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESYESNOOther: enter details here NOWindsor CourtPage 34 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of Windsor Court confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Windsor Court am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Windsor CourtPage 35 Windsor Court / 17th March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000060372.V205621.R01© This report may only be used in its entirety. 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