Inspection on 07/11/05 for Windsor Court Residential Home

This inspection was carried out on 7th November 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 10/08/05

Windsor Court Residential Home 17/03/05

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

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 Residential Home 44 - 50 Windsor Road Oxbridge Stockton-on-Tees TS18 4DZ Lead Inspector Katherine Acheson Unannounced Inspection 7th November 2005 12:20 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 Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Windsor Court Residential Home Address 44 - 50 Windsor Road Oxbridge Stockton-on-Tees TS18 4DZ 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) 01642 618276 01642 618276 Oxbridge Care Limited Mrs Yvonne Macdonald Care Home 30 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (20) of places Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10/08/2005 Brief Description of the Service: Windsor Court is registered to provide personal care to a maximum number of thirty older people. The home is divided into two separate units. The ground floor of the home accommodates a maximum number of ten older people with dementia. This unit has a communal lounge, a separate dining room and communal toilet/bathing facilities; all bedrooms are single in nature. There is also a unit that accommodates a maximum number of twenty older people. This unit has two lounge areas, one designated for those residents who wish to smoke, a separate dining room and toilet facilities on the ground floor of the home, however bedrooms and bathing facilities are on the first floor. All bedrooms are single in nature. 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. All bedrooms in the home environment meet size requirements of National Minimum Standards, a total of five have en-suite facilities, which comprises of a toilet and hand washbasin. To the rear of the home there is an enclosed garden area and parking facilities for staff and visitors. Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection started at 12:20pm and lasted for just over four and a half hours. Four residents, one relative and the Manager were spoken to during the inspection. Staff were spoken to informally. Numerous records including medication, policies/procedures, menus, and staff recruitment and training records were examined. A tour of the home was carried out. Requirements highlighted at the last inspection in July 2005 were re-visited. Fifteen comment cards were received in respect of Windsor court. Comment cards were on the whole very positive about life in the home, however, six commented that they did not feel that their were sufficient and suitable activities and three commented that they did not always like the food that was provided. What the service does well: What has improved since the last inspection? The Manager has worked extremely hard since last inspection to ensure that all requirements highlighted at the last inspection had been addressed. It is evident from the inspection that the Manager takes great pride in her work. Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 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 Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The above standards were not inspected. Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: The above standards were not inspected in full, however a number of areas in respect of medication systems and practice were identified at the last inspection in August 2005 as requiring immediate improvement and further development. Since last inspection the home’s medication policy has been updated, staff have received further medication training and the Manager now carries out a regular audit of all medication ordered, received and administered to residents. It was also highlighted at the last inspection that the current care planning for residents highlights all needs and medical problems for each resident collectively and that resident care plans could be enhanced further by highlighting and evaluating on problems individually. The Manager informed the Inspector that as yet this has not been carried out. Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 Page 10 Four residents and one relative were spoken to during the inspection all of who spoke positively about their life in the home. One resident said, “It’s just like being at home” another said, “I am very contented it is better than being on my own”, another said, “It’s a very good place to be”. One relative spoken to during the inspection said, “I think that the home is lovely, the staff are wonderful and I am made to feel very welcome”. Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Mixed comments were received from residents and relatives in respect of the food that is provided. The home would benefit from involving residents and relatives in a review of menu’s and food provided to ensure an appealing and nutritious diet. EVIDENCE: The home offers a four-week menu with an alternative choice available at each mealtime. Menus examined showed variety. Records were available to confirm that appropriate temperature checks are carried out on fridge, freezers and food. Records of food provided were available for inspection. Fifteen comment cards were received in respect of the home from residents and relatives, twelve of which informed the inspector that they liked the food that is provided, three of who stated that they did not always like the food that is provided. One resident spoken to during the inspection said “The food on the whole is good, there is always choice available”, another said, “No one goes to bed hungry, another said, “I don’t always like the food. The relative spoken to during the inspection said, “The food is wonderful” Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 Page 12 The food was sampled during the inspection and found to be tasty and well presented. Mealtime was observed to be pleasant and relaxed. Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 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): 18 The home’s adult protection policy/procedure and training that staff have received helps protect residents from abuse. EVIDENCE: The home has an adult protection policy/procedure in place which details action that staff must follow if abuse is suspected. The Manager said that staff at the home have received adult protection training, documentary evidence was available on staff files examined at random to confirm that this was the case. Residents spoken to during the inspection confirmed that they felt safe living at Windsor Court. Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 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, 20, 21, 22, 23, 24, 25, 26 The home is warm, welcoming and friendly. Re-decoration, replacing chairs and replacing the carpet in those areas identified would enhance the home environment for residents. The homes policy/procedure for cross infection does not contain detailed information and best practice to follow to control the spread of infection. EVIDENCE: A tour of the premises found the home to be warm, welcoming and friendly. Suitable communal space is provided for residents and these areas are decorated in a homely and comfortable manner, however, the lounge designated for those residents that wish to smoke requires re-decoration and replacement flooring. Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 Page 15 Residents’ bedrooms are homely and personalised with many personal belongings being evident. The carpets in bedrooms 17 and 22 were observed to be worn and marked and must be replaced. A number of chairs in the home environment were observed to be worn and in poor condition, this was pointed out to the Provider at the time of the inspection who said that he would purchase a number of new chairs. The home’s toilets/bathrooms and showers were observed to be of a satisfactory standard, however the flooring in the bathroom area on the dementia unit requires replacing. The Manager said that all showers, sinks and baths in the home environment are temperature regulated and that staff at the home take and record the temperatures on a regular basis to ensure that they are within normal limits. Records were available to confirm that this was the case. The Registered Provider said that he is suitably qualified to service the thermostatic mixing valves and that he does so on a regular basis, however records were not available to confirm that this was the case. The home has two hoists, one electric and one manual. Records were available to confirm that the electric hoist is serviced on a regular basis, however the manual hoist had not. The Registered Provider said that he would take immediate action to address this. Externally the home is fairly well maintained there is a pleasant enclosed garden area for residents on both units to share. The gate that leads to the main car park of the home requires replacing. On the day of the inspection the home was clean and odour free. The homes infection control policy requires reviewing and updating to include current practices and procedures. Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 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): 28, 30 Staff receive appropriate training to ensure that care needs of residents are met. EVIDENCE: The Manager said that seven out of fourteen care staff have achieved an NVQ level 2 in Care, and the majority of other care staff have registered and are working towards achieving their NVQ level 2. It was evident following discussion, that the Manager considers training of staff to be a high priority. Staff have received appropriate mandatory training and other training relevant to the job that they do. It was highlighted at the last inspection in August 2005 that the staff must not be employed to work at the home prior to the receipt of a satisfactory POVAfirst/Criminal Record Bureau Check. Examination of staff records sampled at random confirmed that the home is now following the correct. procedure. Since last inspection the Manager has updated the home’s recruitment procedure and commenced on all new staff working at the home an induction that includes all of the required elements. Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 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 The Manager is working extremely hard to ensure the effective and efficient running of the home. The home seeks the views of residents and their families to ensure that it is managed with their best interest. The home ensures that the financial wellbeing of residents is safeguarded and protected. EVIDENCE: The Manager Yvonne Macdonald has been the Registered Manager of Windsor Court since August 2005. Yvonne has achieved an appropriate care qualification and is currently working towards achieving her NVQ level 4 in Management. Staff spoken to during the inspection spoke highly of the Registered Provider, Manager, staff team and care that is provided. One resident said, “I have freedom of speech, it’s a very good place to be”. Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 Page 18 The Manager has a quality assurance system in place. A survey/questionnaire is sent out to residents and relatives on a six monthly basis asking if they are happy with the care that is being received and other areas relevant to the resident and home. A discussion took place with the Manager regarding publishing the results of the survey. The home operates an effective system in which they look after the personal allowance of a number of residents. Accurate records of transactions and receipts were available for examination. Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 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 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 2 2 2 3 2 2 2 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X X Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 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 OP20 Regulation 16, 23 Requirement Timescale for action 30/04/06 2 3 OP20 OP21 4 5 6 7 OP21 OP22 OP24 OP26 The lounge designated for those residents that wish to smoke must be re-decorated and the flooring replaced 13, 16, 23 The gate that leads from the garden to the car park must be replaced 13 • Thermostatic mixing valves must be services on a six monthly basis • The Registered Person must provide evidence of being suitably trained to carry out the servicing of the thermostatic mixing valves 16, 23 The flooring in the bathroom on the dementia unit must be replaced 13 Hoists and slings in the home environment must be services on a six monthly basis 16, 23 The carpet in bedroom 17 and 22 must be replaced 13 The homes infection control policy must be reviewed/updated in accordance with relevant legislation and published professional guidance DS0000060372.V250973.R01.S.doc 30/04/06 30/12/05 30/05/06 07/11/05 30/04/05 30/03/06 Windsor Court Residential Home Version 5.0 Page 21 8 OP33 24 The results of the residents/relatives survey must be published and made available 30/12/05 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. • 2. 3 OP31 OP15 Care plans should include limitations of residents and assistance required Care plans would benefit from being individually evaluated. The Manager should continue working towards achieving her NVQ level 4 in Management by December 2005. A review of the home’s menu’s and food provided should be carried out with residents and relatives • Windsor Court Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Tees Valley Area Office 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 Residential Home DS0000060372.V250973.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!