Inspection on 01/10/05 for Windsor House

This inspection was carried out on 1st October 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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Windsor House 22/06/09

Windsor House 02/12/08

Windsor House 19/12/07

Windsor House 05/02/07

Windsor House 09/05/06

Windsor House 12/04/05

Windsor House 23/11/04

Windsor House 30/07/04

Windsor House 19/05/04

Windsor House 19/11/03

Windsor House 07/10/03

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

CARE HOME ADULTS 18-65 Windsor House 9 Cabbell Road Cromer Norfolk NR27 9HU Lead Inspector Ann Catterick Unannounced Inspection 1st October 2005 09:30a Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 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 DS0000027290.V254757.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 Adults 18-65. 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 DS0000027290.V254757.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Windsor House Address 9 Cabbell Road Cromer Norfolk NR27 9HU 01263 511438 01263 511141 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 Robert Jeans Mrs Sarah Jeans Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Ten (10) people with a Learning Disability may be accommodated. Date of last inspection 12th April 2005 Brief Description of the Service: Windsor House is a care home providing personal care and accommodation for up to 10 adults with learning disabilities. There were 10 people living in the home on the day of inspection. The Registered Providers are Sarah and Robert Jeans and the manager is Mrs Rachel Stevens. Rachel is completing her registered managers award and has made application to become the registered manager. The home is located very close to the sea in the coastal town of Cromer and is close to shops, pubs and all local amenities. Windsor House is a large Edwardian terraced property with accommodation on four floors. The fourth floor is living accommodation for the manager. The property has been in a poor state of repair but the proprietor is in the process of making improvements throughout the home. Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on the morning of Saturday the 1st of October 2005. The inspection took place over 3 hours. On arrival to the home three service were up and others were in the process of getting up or had chosen to have a lay in. Two staff were on duty, including the manager. As service users got up they were offered breakfast which was toast and tea. There appeared to be no plan for the morning and as service users drifted down they had breakfast in the dining area and went to sit in the lounge. The inspector was aware her visit might have had some impact on the morning. One service user was hoping to go into the town with the afternoon staff. Some of those service users living in the home have communication difficulties and would not find it easy to express preferences without some encouragement and options offered by staff. Most service users attend workshops and activities during Monday to Friday. All service users appeared content and settled in their environment and the relationship between staff and service users was good. The rota showed that no additional staff were on duty at weekends and the inspector felt that this would have given more opportunity for staff to be involved with activities for the service users. The home does not employ a cook and one member of staff would be involved in cooking for part of the day. The home does not have a mini bus and not all service users could access public transport so those service users with poor mobility are limited in where they can go. All service users spoken to, and met, appeared to be content and happy in the home. The inspector was concerned that their expectations might be low and the opportunity to try a variety of experiences is limited by numbers of staff on duty and the lack of transport. In conclusion there is ample opportunity and need for improvements in several areas. What the service does well: Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 6 All of the service users are settled in the home and appear to have a good relationship with the staff. The home appears to be retaining it present staff group and this is offering continuity of care for service users. What has improved since the last inspection? What they could do better: The inspection took place on a Saturday morning. All service users were at home and it would be expected that some options for activities or outings be in place. There appeared to be no plans or options of activities for the day. The home offers care to some service users with poor mobility and as the home has no mini bus this limits their opportunities. It is perfectly acceptable for service users to stay at home at the weekend if that is their choice however on the day of inspection there did not appear to be any other choice. One service user was looking forward to going to the shops with a staff member in the afternoon. Enabling service users to reach their full potential and to be able to choose how to spend their weekends from a range of option is essential for personal development. The plans of care were not looked at on this occasion but they will be looked at in significant detail at the next inspection especially around the hobbies, interests and preferences of service users. A member of staff had called in sick earlier in the week and staff had been working up to seventeen hours without a break. This is not acceptable and could put service users and staff at risk. The home would need to employ agency staff if they were not able to cover shifts. The rota was not being managed well. A requirement to address this matter immediately was made on the day of inspection. Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 7 The manager has still not completed all of the administrative tasks in relation to her role. A requirement was made that these tasks be completed immediately. Some of the furniture in the lounge was of poor quality and a requirement was made that some of this was immediately replaced. The manager has a good relationship with staff and service users but some of the concerns identified in this report relate to poor management practices. The manager should have at least 20hrs a week to fulfil her management responsibilities and she appears to spend too much time working shifts on the rota or sleeping in. 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 House DS0000027290.V254757.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected on this occasion. EVIDENCE: Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected on this occasion. EVIDENCE: Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 17 Service users are able to take part in some peer and culturally appropriate activities. Service users are involved in some of the facilities within the local community but there is opportunity for service users to access more of these facilities. Some leisure activities take place but the rota did not take into account the need for more staff at weekends to enable staff to be involved in these. There was limited food in the home on the day of inspection and the menu was not being followed. Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 12 EVIDENCE: Some of the service users in the home have mobility difficulties and would need transport to enable them to go into the local community. In the past there has been suggestion that the home will purchase a mini bus but this has not yet materialised. It was suggested that service users could be taken out in wheelchairs but a member of staff said that this hurt her back, as the chair was old. If the chair was suitable and correct manual handling practice was in place this should not be an issue. The inspector felt general concern that there appeared to be no effort to offer leisure and social opportunities to the service users at the weekend and service users were offered no direction from staff. The phrase, “service users choice”, was voiced on several occasions and the inspector accepts that service users have the right to choose what they want to do. However it appeared that service users had rather low expectations and staff were not able to offer a variety of options for service users to choose from. On the day of inspection the only plan for service users appeared to be that one service user was to go into the town with one of the afternoon staff. Access to transport is imperative if the service users are to have more choices and opportunities in their social life. The home also needs to ensure that the staff rota reflects the needs of the service users and it would be expected that more staff were on duty at busy times during the weekend. Most service users attend workshops or are involved in work or activities between Monday and Friday. The inspection took place on a Saturday and the weekly menu offers a cooked lunch at weekends and a buffet tea. The menu stated spaghetti bolognaise for lunch but there was no evidence to suggest there were plans to cook this. On the day of inspection the dry storeroom was seen and all food was economy supermarket savers. Other than margarine there was little in the fridge. Service users were offered toast for breakfast and one service user was seen have a tin of soup for lunch. When staff were questioned about the lunch time menu it was suggested that it was not worth cooking spaghetti bolognaise if nobody liked it. This is acceptable but a suitable alternative should have been offered. The home has no cook and all food is prepared by staff. This is an area that needs to be improved to ensure that service users are receiving a nutritional, well- balanced wholesome diet. Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The procedure for the care and administration of medication was inspected and the outcome for this standard was partly met. EVIDENCE: The process that takes place in relation to the receipt, storage, administration and disposal of medication was inspected. There were no concerns about this procedure but the cupboard in which the medication was stored was a newly built cupboard and the wall had not been completely finished. There was a musky sort of smell in the cupboard and this needs to be investigated to ensure that the cupboard is not damp. The staff member who was on duty on the day of inspection has worked in the home for many years and administers medication but has not had any formal training in this area. A requirement has been made. Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected on this occasion. EVIDENCE: Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 28 The home environment has improved a little but there is potential for further improvement to make it a homely comfortable environment. The quality of some of the accommodation in shared spaces was not acceptable. EVIDENCE: The proprietor is slowly improving the property and some areas of the home have been redecorated. The bathroom on the first floor is much improved and the radiator has been covered since the time of the last inspection. One service user was happy to invite me into her room and this had been redecorated and had a new carpet. One of the service users toilets was not accessible to them as it was waiting repair. A settee in the lounge was in such a poor state of repair that an immediate requirement to replace it was made. The laundry is in the cellar and the areas needs to be refurbished as the walls and flooring are of poor quality. Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 33 Staff in the home have not all completed the necessary qualifications and training to complete their roles. Service users are not supported by an effective staff team, with sufficient numbers, to support service users assessed needs at all times EVIDENCE: On the day of inspection the manager was on shift with a carer. The carer had worked in the home for many years and administered medication but had received no formal training in this area. There had been no concerns about her practice but training would ensure that she was up to date with modern thinking and practice. A requirement has been made in this area. The rota for the week was inspected and due to sickness there had been some shifts on the rota, especially waking nights, which needed to be covered. The home had no relief staff and agency staff were not asked to cover the shift. The manager dealt with this situation by allowing one member of staff to work 17hrs without a break with no day off before continuing to work a double shift. Other staff were allowed to work day shifts and waking night shifts with little time off in between shifts. This is not acceptable and if staff are tired and overworked this could put service users and staff at risk. An immediate requirement was made in this area. Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 38 It is judged that the general outcome of this inspection does not suggest that this is a well run home. It is judged that service users do not always benefit from the ethos leadership and management within the home. Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 18 EVIDENCE: The manager has over two years experience of managing the home. The manager has not commenced her NVQ level 4. The manager has made application to become registered manager and this has been a protracted and lengthy process due some difficulties the manager had in completing her application. This process has not yet reached its final conclusion. The manager is open and inclusive within the home and relates well to staff and service users. The manager still continues to work shifts, as on the day of inspection, and, “sleep ins,” therefore not appearing to have enough time to complete all of her management responsibilities. There is concern on her ability to manager all of those areas that are her responsibility and the way she has dealt with a shortage of staff on the rota the week prior to the inspection has evidenced this. Windsor House DS0000027290.V254757.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 Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X 1 X X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 1 X X X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Windsor House Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 1 2 X X X X X DS0000027290.V254757.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA17 Regulation 16(i) Requirement The registered person must ensure that service users are provided with suitable, wholesome and nutritious food. The registered person must ensure that all staff that administers medication are appropriately trained. The registered person must ensure that the furniture in the communal areas is adequate for service users needs. This requirement was an immediate requirement. The registered person must ensure that there are at all times suitably qualified, competent and experienced persons working at the home in such numbers as are appropriate for the health and welfare of service users. This requirement was an immediate requirement. The registered person must ensure that all of those matters specified in Schedule 2 in the Care Home Regulations have been sought for the manager. This requirement was an immediate requirement. DS0000027290.V254757.R01.S.doc Timescale for action 01/11/05 2. YA20 13(2) 01/12/05 3. YA24 23(g) 07/10/05 4. YA33 18(1)(a) 02/10/05 5. YA37 9(2)©(1) 03/10/05 Windsor House Version 5.0 Page 21 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 YA17 Good Practice Recommendations The provision of meals within the day workshops service users attend has altered and therefore staff need to ensure that evening meals are varied and nutritious as these are now, for most service users, the main meal of the day. That now that the home is full and most service users have their main meal in the evening that consideration be given to employing a cook at this time to allow care staff on duty to spend more time with service users. A cook would also be of benefit at weekends. That if following assessment it is identified that some service users are not able to access public transport the proprietor give consideration to purchasing a mini bus to ensure the social needs of all service users are met. 2. YA33 3. YA14 Windsor House DS0000027290.V254757.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. 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