Inspection on 01/05/07 for Windsor House

This inspection was carried out on 1st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 House 12/09/06

Windsor House 09/05/06

Windsor House 24/11/05

Windsor House 23/06/05

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Windsor House Windsor House 209 Wigan Road Standish Wigan WN6 0AE Lead Inspector Kath Smethurst Unannounced Inspection 1st May 2007 10:00 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 House DS0000062654.V335467.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windsor House Address Windsor House 209 Wigan Road Standish Wigan WN6 0AE 01257 421325 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) Mr Ghulam Haider ** Post Vacant *** Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16), Physical disability over 65 years of age (2) of places Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 16 service users to include:up to 16 service users in the category of OP (Older People over 65 years of age) up to 2 service users in the category of PD(E) (Physical Disability over 65 years of age) The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. The Registered Person must ensure that a varied range of activities is planned and implemented by 31/1/05 22nd February 2007 2. 3. Date of last inspection Brief Description of the Service: Windsor House is a large detached property in Standish. The home is situated on the main road to Wigan and Standish town centres and is approximately five minutes drive from local amenities. The front of the home offers impressive views over fields and the countryside. Car parking is available at the front of the home, and there is a large well-maintained garden at the rear of the premises. There are five double and six single bedrooms. There are no en-suite facilities but toilets and bathrooms are situated close to bedrooms. The home provides personal care and support for sixteen residents over the age of sixtyfive. Fees are £345 per week. Additional charges are made for hairdressing and transport. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection at Windsor House took place over 5 hours. The home had not been told that the inspector would visit. The inspector looked at records the home holds on residents (care plans) and other records the home needs to keep to ensure the home is being run properly, such as activity records, menus, staff files and staff training records. The inspector also looked around the building. An extra visit had been made to the home in February 2007 to make sure they had completed all the things they needed to do from the inspection in September 2006. To find out more information the inspector spoke to a number of residents. The manager, two care staff and the cook were spoken with. A visiting pharmacist was also spoken with. Comment cards, asking residents and relatives and other visitors to the home such as doctors and the district nurses what they thought about the home and the care provided were sent out prior to the inspection. Eight residents and one relative returned comment cards. All were satisfied with the care provided. Comments received included the following. “Staff are of a high standard and take a great interest in residents”. “Excellent care within Windsor House”. “The activities are there but normally I don’t wish to take part”. What the service does well: From speaking to residents and the information residents and relatives gave in the comment cards, it was clear that they were happy with the care provided. Staff were described as “very nice”, “very good”, and “lovely”. The home makes sure that before staff start work they are properly checked to make sure they are suitable to care for people living in the home. Residents were very satisfied with the food stating they got enough, that they were given choices and meals were home cooked. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: To make sure any complaints made by residents or their relatives don’t get overlooked details need to be written down as well as what was done to put things right. To ensure the home remains comfortable for people living there plans need to be made to replace some chairs, curtains and bedroom furniture. To make sure residents (if possible) and staff have taken part in a fire drill,l details of exactly who has taken part needs to be recorded. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 8 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 House DS0000062654.V335467.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are properly assessed prior to admission so ensuring the home is able to meet any identified needs. EVIDENCE: During the key inspection undertaken on the 12th September 2007 concerns were raised in respect of the assessment process. Examination of residents care records indicated some residents had been admitted without a proper assessment having being completed. During inspection visit undertaken in February 2007 good progress had been made in improving the assessment process. The new manager introduced new assessment documentation, which covered all required areas. The manager had also been proactive in requesting Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 10 re-assessments by care managers where she felt the home could not meet some specialised care needs. It was pleasing to note that improvements made to the assessment process had been maintained. There have been no permanent admissions since the last inspection. The manager advised that a resident was due to be admitted to the home the following week for a period of respite care. The pre-admission assessment for this resident was inspected. This resident’s care was funded by social services and a copy of the care management assessment had been obtained. The manager had also visited the prospective resident at home and completed an additional assessment of care needs. The assessment document was detailed and included information relating to physical and social care needs. Feedback in returned resident and relative comment cards indicated they had been provided with sufficient information prior to admission. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health and care needs were well met and care plans provide clear guidance to staff in each area of residents care needs, providing staff with the information they need when delivering care. Residents were treated with dignity and respect and their right to privacy was upheld. EVIDENCE: During the inspection undertaken in September 2006 care plans were found to be poorly maintained. During the inspection undertaken in February 2007 significant improvements were noted in the care planning process. During this inspection the progress made had been maintained and further improvements had also been made. Two care plans were examined. All contained comprehensive information relating to residents personal, social and health care needs. Each area of risk has a separate record. Supplementary information includes a personal care Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 12 and weight record. Daily entries in care notes were completed in all the plans examined and gave a good indication of the care provided and residents well being. The plans were easy to read, had been regularly reviewed and set out clear guidance for staff to take when providing care. In addition day and night care plans were in place, which provided staff some very good information about resident’s preferences and chosen lifestyle. For example one plan read, “Doesn’t like her curtains closed at night”, a second “Sleeps better if the light is left on”. Work has also begun on compiling social histories. Once completed the information will gave readers a good insight as to the people, things and events important to residents. Feedback from residents (able to comment) was very complimentary about staff and the care provided. A relative who returned comment cards were also pleased with the standard of care. One relative wrote, “Excellent care within Windsor House-well qualified and certainly enthusiastic and caring staff”. The services of opticians, dentists, chiropodist and audiologist were accessed either at the home or in the community as and when necessary. Care plans recorded GP, opticians and chiropodist visits. Residents spoken with and those who returned comment cards confirmed they received medical support when they needed it. When asked if they received the medical support they needed all answered “Always”. A pharmacy inspection was carried out by Stephanie West (CSCI Inspector) during the inspection undertaken in September 2006. Some weaknesses were found in record keeping and the administration of medication. It was also found that staff had not received appropriate training. During this inspection the requirements made following this inspection were looked at and found to have been addressed. Procedures are in place that described safe medication handling. Staff responsible for the administration of medication have now completed training. A separate facility is provided for the storage of medication. A lockable drug trolley is provided which when not in use is secured to the wall. A domestic fridge is used to store items such as eye drops. While functional it is recommended that a lockable medication fridge be provided. Currently none of the residents have been prescribed controlled drugs, but if the need arose a separate system for recording the administration of controlled drugs is in place and separate storage is provided. Medication storage was orderly with no evidence of overstocking. Accurate records were in place for the receipt and disposal of medication. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 13 The home uses a monitored dosage system supplied by a local pharmacist. Medication Administration Records (MAR) are supplied by the pharmacy except for example when additional medication is provided mid month. Photographs were used between resident’s medication administration records to help with positive identification. Samples of MAR (Medication Administration Records) were examined and were found to be clear and up to date. The supplying pharmacist visits regularly to undertake medication audits. He was present on the day of the inspection and was spoken with. He indicated that since the new manager has been in post medication handling in the home has improved significantly. Those residents who were able to comment and feedback in returned resident/ relative comment cards, indicated staff respected their privacy and dignity. During the inspection, staff were observed to treat residents with respect and consideration. Residents were observed to be dressed in clean well maintained clothing. Staff were observed knocking on doors before entering rooms and toilets. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s interests and links with visitors are encouraged, ensuring residents live as normal a life as possible. Meals are good and the needs of residents are well catered for with a balanced and varied selection of food provided. EVIDENCE: During the inspection undertaken in September 2006 it was found that the range and frequency of activities needed to be increased. At the inspection visit undertaken in February 2007 the provision of activities has improved significantly. At this inspection the improvements noted had been maintained. An activity co-ordinator is employed who works five days a week from 10am to 1pm. On the day of the visit the co-ordinator was on holiday so it was not possible to speak to her about her role. Despite her absence there was evidence to demonstrate activities now take place both inside and outside the home on a regular basis. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 15 Written records of the activities individual residents take part in are documented. Recent activities residents have taken part in include pub lunches, a bus trip, pat a pet, bingo, dancing, reminiscence, party, shopping, pamper day, baking and card making. The mobile library visits the home on a monthly basis. A monthly trip is also arranged. Recent trips include lunch at Smithalls Coaching House followed by an Old Time Music Hall entertainment and a visit to Wigan Pier and a boat trip. Residents said they enjoyed the trips out. Details of the activities arranged for each week are also displayed on the notice board. A photographic record is also maintained of the activities residents take part in. Good practice was noted in that more one to one activities also take place. For example although the activity co-ordinator was on holiday a member of staff supported a resident to go shopping in the afternoon. Staff were also observed socialising with residents throughout the course of the visit. Residents spoken with confirmed the provision of activities had increased and this was appreciated. Residents with religious beliefs are encouraged and enabled to maintain links. Care plans contain details of resident’s preferred religion. The home has an open visiting policy. There are no restrictions on the time people visit, evidence of which was highlighted in the visitor’s book where entries showed residents friends and relatives visiting at different times during the day and the evening. The only time restrictions would be imposed is when requested by residents. Visitors spoken with during previous inspection visits indicated they were always made welcome by staff. Residents who were able to comment expressed satisfaction with the care provided and organisation of life in the home. One resident spoken with indicated he liked to go out shopping and staff made sure he was able to do so. It should be noted a number of residents have memory and communication difficulties so were unable to confirm they were able to exercise choice. Nevertheless observation of care practice indicated residents could make some choices for example in regard to meals and where they spent their day. Resident’s rooms are personalised and residents are able to bring personal items in the home. The menus were inspected and were found to be well balanced and varied. And while choice is not offered in the menu alternatives are provided. An example of which was seen on the day of the visit where the cook was observed discussing with a resident what he wanted for tea. Breakfast comprises a choice of cereals and toast. A cooked breakfast is not on the menu but care staff advised one would be provided on request. The Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 16 lunchtime meal was observed. The dining area was clean and tables were set with linen tablecloths. The cook served the meal. On the day the meal consisted of sausage, egg, tomatoes followed by rice pudding. No one was rushed and second helpings offered. Very little convenience foods are used. The cook indicated that the budget was sufficient. One of the residents required assistance with eating. This resident was not brought to the table through personal choice. Good practice was noted in that the staff member sat beside the resident, told her what the meal was and gave her time to enjoy her meal with support, which was given in a discreet and individual manner. Residents spoken with and those who returned comment cards had no complaints about the quality, quantity and choice of food provided. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents knew how to complain, but the absence of a system for recording how complaints are dealt with could result in resident’s views not being acted upon. Policies, procedures and training were in place to safeguard residents from abuse or harm. EVIDENCE: A complaints procedure is in place, which gives details of how a complaint will be investigated. Details of how to complain are displayed. Information in the pre-inspection questionnaire indicated there had been no complaints since the last inspection. No formal complaints have been received by the CSCI. Residents spoken with and those who returned comment cards indicated they felt able to approach staff with any concerns and these would be taken seriously. None had made a complaint but all indicated they were aware of how to do so if the need arose. While residents felt confident any concerns/complaints would be addressed, some improvements are needed. Currently a system to record any concerns or complaints residents or their representative’s may have is not in place. Discussion with the manager indicated that any complaints would be dealt appropriately. However further development is needed to ensure issues Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 18 brought to staffs attention are not overlooked. A system needs to be implemented where details of any complaint/concern, investigation, outcome and action taken are documented. The manager offered assurances this would be addressed. This would also be beneficial for the manager as part of the quality assurance monitoring process. An Adult Protection and Prevention of Abuse policy is now in place, which incorporates, whistle blowing. The home ensures all staff completes a POVA and CRB (Protection of Vulnerable Adults Register/Criminal Records Bureau) check before they commence work. No recent POVA (Protection of Vulnerable Adults) investigations have taken place. The majority of staff have completed POVA training and further training has been arranged in the near future for those staff who have not completed the course. Staff spoken with understood the importance of reporting any allegations or suspicion of abuse. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A recent programme of decoration and refurbishment has resulted in improvements, providing residents with a clean, pleasant and comfortable environment. EVIDENCE: Windsor House is a large detached property in Standish. The home is situated on the main road to Wigan and Standish town centres and is approximately five minutes drive from local amenities. The front of the home offers impressive views over fields and the countryside. Car parking is available at the front of the home, and there is a large well-maintained garden at the rear of the premises. Fixtures and fittings are domestic in style and the addition of flowers, pictures and ornaments add to the homely atmosphere. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 20 Since the last inspection improvements to the standard of the environment have been made. Radiators have been fitted with covers. New carpets, dining tables/chairs, curtains and some lounge chairs have been replaced. These improvements have improved the environment considerably. It was however noted that some of the lounge chairs have not yet been replaced and while functional consideration should be given to replacing the remaining (9) chairs so all residents have the benefit of new furniture. Since the last inspection work has also begun in upgrading bathing facilities. The installation of a new walk in shower is nearly complete. This will make a big difference to residents providing them with a choice of having either a bath or shower. It was noted that while functional the fixtures and fittings in the remaining bathrooms were somewhat dated. Consideration should be given to replacing toilets, wash hand basins and baths on a gradual basis. A sample of bedrooms was examined. The bedrooms viewed were personalised with photographs and personal mementoes on display. Doors are fitted with locks that can be opened by staff in an emergency. During previous inspections it was identified some vanity units, wardrobes, lockers and drawers were old and showing signs of wear and tear. This remains relevant and plans should be made to replace these items as part of the renewal programme, as if left standards will fall below an acceptable level. It was also noted that the curtains in rooms 5, 2, and 4 were showing signs of wear and would benefit from being replaced. On the day of the visit the home was clean and odour control was very good. The laundry was sited away from food preparation areas and was seen to be clean and orderly. Sufficient and suitable equipment was provided. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels are satisfactory ensuring consistency of care for people living in the home. The residents were cared for by staff that were safely recruited, suitably experienced and trained to meet the residents care needs. EVIDENCE: During the inspection undertaken in September 2006 concerns were raised regarding the number of hours staff worked and domestic and night staff cover. The new manager has taken steps to address these issues. An additional cook has been recruited. The cooks now work until 6pm so care staff no longer prepare the evening meal. Concerns were also raised regarding staffing arrangements at night. One member of staff was on waking duty (supporting 16 residents) with an additional member of staff providing sleep in cover. The new manager undertook a review and as a result two staff are now on waking night duty. This is a positive initiative, which will be of benefit to the residents. Good practice was noted in that the manager has also introduced handovers at the start and end of each shift. This ensures staff coming on duty are aware of any issues relating to individual residents. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 22 On the day of the visit staffing levels were sufficient to meet the needs of the residents. A written rota is maintained and showed when staff were on holiday or sick leave, and what was covered. Staff spoken with indicated staffing levels were sufficient. The manager said she would have no hesitation in increasing staff ratios should the need arise. A number of overseas staff works at the home. This does not appear problematical as they speak very good English. All but one have good English written skills. The member of staff who is not confident in her written skills is currently undertaking English classes at college. The atmosphere in the home was very relaxed and friendly. Interactions between staff and residents were frequent, natural and warm. A friendly but respectful banter was observed. Residents had no hesitation in approaching staff. Staff were observed to respond speedily to requests for assistance made by residents and they also spent time socialising with them. The files of three staff employed looked at showed all necessary recruitment checks had been undertaken. All contained: written application forms, 2 references, Criminal Records Bureau (CRB) check and verification of identification. The provision of training opportunities for staff has improved considerably since the inspection undertaken in September 2006. The new manager has worked very hard to ensure the requirements made relating to training have been addressed. She is commended for her efforts in this area particularly as prior to her appointment very little training was provided. The manger has introduced a new induction training programme (Developing Competent Carers) that meets the National Training Organisation (NTO) specifications. No new staff have been employed since the inspection undertaken in February 2007. During that visit the induction record of the most recently employed member of staff was examined to find all relevant areas had been completed. Good practice was also noted in that the manager was completing the induction programme with a member of staff who had returned from maternity leave. The training matrix was examined and confirmed mandatory training needs were now being well met. Recent courses undertaken include, first aid, moving and handling, food hygiene, medication, protection of vulnerable adults and dementia care training. Now mandatory needs have been addressed the manager has begun to look at the provision of more specialised training. As previously noted some staff has completed dementia awareness training and continence awareness training has been arranged. Good progress was also noted in regard to the provision of NVQ (National Vocational Qualification) training for staff. During the inspection undertaken in Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 23 September 2006 the percentage of staff with NVQ level 2 was low. It was pleasing to note that all staff not in receipt of NVQ (National Vocational Qualification) level 2 are now completing training. Two staff are coming to the end of their training and once completed 50 of staff will be in receipt of NVQ level 2. Staff spoken with were more than satisfied with the training opportunities provided. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is experienced and competent ensuring the home is run in the best interests of the residents. Regular maintenance and fire safety checks were carried out, promoting the health and safety of both residents and staff. EVIDENCE: Jane Round has been appointed as manager of Windsor House following the inspection undertaken in September 2006. The manager has extensive experience in caring for older people and has obtained the NVQ (National Vocational Qualification) level 4 registered managers award. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 25 The new manager took over when the home was failing. Previous management had been weak and there were serious concerns regarding the running of the home. She has made good progress in addressing many of the requirements made during the inspection undertaken in September 2006. She has improved care plans, training, activities, policies, procedures and the environment. The manager has also kept in regular contact with the CSCI providing information on a regular basis regarding progress in addressing requirements made. The new manager has a good understanding of the areas in which the home still needs to improve upon and she has drawn up a list of priority areas to address which she is working through in a planned way. It is evident from the findings in this inspection she has worked very hard to improve standards in the home and is commended for her efforts. There is now a clear line of accountability in the home which residents and staff are aware of. Record keeping is now in the main good and residents and relatives indicated they are satisfied with the care and organisation of life in the home. During the inspection, it was observed that residents and staff had no hesitation in approaching the manager if they had anything they wished to discuss. Staff described the manager as being “fair” and “approachable”. Staff felt the home had improved since the new manager has been in post. Significant improvements have been made to quality assurance systems in the home since the inspection undertaken in September 2006. Regular staff and resident meetings now take place and are minuted. Minutes of the residents meetings are displayed on the notice board for those residents who choose not to attend. The owner visits the home on a regular basis to audit records and speak to residents and staff. A written report is then produced of the findings, which is then forwarded to the CSCI. While improvements have been made further development is needed. As previously noted a system of recording the concerns/complaints made needs to be introduced. It was also suggested that satisfaction surveys should be sent to residents and relatives in order to ascertain their views. The manager took immediate action in this respect and following the inspection forwarded a sample satisfaction survey she had produced and was planning to send. The home has a satisfactory accounting system in place. Staff could determine exactly how much money the home was holding for each resident. The Home looks after small amounts of resident’s personal allowances. Detailed records are held of all transactions. All monies held for safekeeping are kept individually. A record is kept of monies credited and debited and receipts were obtained for financial transactions. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 26 Health and safety policies and procedures were in place. The staff team have completed health and safety training. Accidents had been recorded appropriately. With the pre-inspection materials, the manager provided a list of maintenance and associated records. A number were checked on the site visit on the 1st May 2007, including the lift, nurse call system, fire equipment and gas. All but the gas certificate were up to date. The manager forwarded an up to date gas safety certificate to the CSCI following the inspection. Fire safety records showed that that all fire tests and maintenance procedures had been undertaken regularly. Staff have undertaken fire safety training and a fire risk assessment is in place. While the manager indicated regular fire drills take place these were not logged. This is an area the manager needs to address. Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 27 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 3 X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP16 Regulation 17 (2) 11 Requirement To ensure there is evidence resident’s views are listened to; a system to record complaints must be implemented. To ensure the safety of both residents and staff details of fire drills must be recorded. Timescale for action 01/06/07 2. OP38 17 (2) Schedule 4, 14 01/06/07 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 OP9 Good Practice Recommendations To ensure resident’s medicines are more securely stored consideration should be given to providing a lockable medication fridge. To ensure all residents have the benefit of good quality furnishings plans should be made to replace the remaining lounge chairs. 2. OP19 Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 29 3. OP19 To ensure the environment is pleasant for residents the curtains in the identified bedrooms should be replaced before standards fall below an acceptable standard. To ensure the environment does not fall below an acceptable standard for resident’s plans and as part of the homes planned programme of refurbishment consideration should be given to replacing toilets, sinks and baths. To ensure the environment does not fall below an acceptable standard for residents plans and as part of the homes planned programme of refurbishment consideration should be given to purchasing new vanity units wardrobes, chest of drawers and lockers. 4. OP21 5. OP24 Windsor House DS0000062654.V335467.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 House DS0000062654.V335467.R01.S.doc Version 5.2 Page 31 - 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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