Inspection on 13/10/06 for Windsor House - City of York Council

This inspection was carried out on 13th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 - City of York... 24/09/07

Windsor House - City of York... 19/01/06

Windsor House - City of York... 21/07/05

Windsor House - City of York... 08/11/04

Windsor House - City of York... 28/04/04

Windsor House - City of York... 16/09/03

Windsor House - City of York... 13/05/03

Windsor House - City of York... 28/10/02

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

CARE HOMES FOR OLDER PEOPLE Windsor House - City of York Council Windsor House 22 Ascot Way Acomb York North Yorkshire YO24 4QZ Lead Inspector Jo Bell Key Unannounced Inspection 13th October 2006 09:30 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 - City of York Council DS0000034926.V313794.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 - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windsor House - City of York Council Address Windsor House 22 Ascot Way Acomb York North Yorkshire YO24 4QZ 01904 798 004 01904781828 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) City of York Council *** Post Vacant *** Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: Windsor House is a care home run by City of York Council and registered to provide a service for 31 older people of either gender aged over 65 years who do not have any specialist requirements. Up to 6 day care places are available. The home was purpose-built approximately 35 years ago and is located in Acomb. It is within walking distance of local amenities. There are extensive well-maintained gardens. The accommodation is provided in single rooms on two floors. The upper floor is accessible via passenger lift. The scale of charges are the standard charges through City of York Council. Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection took place on Friday 13th October 2006, one inspector spent five hours in the home. Prior to the visit information was obtained from the pre-inspection questionnaire and a range of comment cards were received from relatives, visitors and health care professionals. The home has undergone some refurbishment and is hoping to develop the service further in the next few months. All outcomes for service users were either excellent or good. The staff provide an excellent standard of care which was commented on by service users, visitors and health care professionals. Service users were happy, well cared for and are provided with a range of activities to meet their needs. The staff have the skills, knowledge and experience to meet all the service users needs. The environment is pleasant, with a range of lounge and dining areas to sit and eat in. No complaints or concerns have been received by the CSCI and during the visit no negative comments were made. What the service does well: Service users all commented positively on the excellent care provided in the home, this was underpinned by the comprehensive care plans in place. The care leaders, care staff, general assistants and the cook have an excellent rapport with the service users and they clearly understand how to meet their needs. A range of activities are provided in the home and service users were observed chatting with staff and reminiscing. Service users are treated with dignity and respect, this was evident throughout the visit. The majority of care staff have obtained an NVQ Level 2 or above, this is a great achievement and has a positive effect for the service users regarding the care that is being delivered. Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 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 House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 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): 3 (Standard 6 is not applicable) The quality outcome in this area is good. Service users have their needs effectively assessed prior to admission to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two assessments were inspected, these had been completed by a care manager prior to the admission. All aspects of social, physical, psychological and medical needs had been discussed. This information was used to inform the initial assessment undertaken by one of the care leaders. Two service users were spoken with who confirmed that these assessments had taken place at their home. Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 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): 7,8,9 & 10 The quality outcome in this area is excellent. Service users health and personal care needs are clearly met. Privacy and dignity is maintained and staff care for service users in a respectful and courteous manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care provided in the home is excellent. Service users were observed looking clean and well dressed, some ladies had visited the hairdressers whilst others were wearing make up. The gentlemen were clean shaved and tidy. All service users were happy and enjoying the banter with the staff team. One care leader who was spoken with was passionate about her work, she had the service users best interests at heart and she understood how individual needs could be met. All of the care team observed, had a similar perspective towards caring for the service users. Two care plans were inspected and these were concise with clear interventions and treatments documented. Service users had discussed and signed these plans. Risk assessments regarding moving and handling, prevention of Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 Page 10 pressure sores and some nutritional assessments were in place. The home has access to GPs, chiropody, dietician, occupational therapist and district nurses. Referrals can be made and both the care leaders and manager were aware of how this works. Staff spoken with are aware of how to detect if a service user is underweight or overweight and what action to take. The home complete Regulation 37 notifications when an incident occurs in the home which effects service users, this is sent to the CSCI. The medication system was discussed and inspected. The care leader confirmed that staff complete an accredited medication course prior to administering medication. Care plans confirmed that medication and self medication is documented, fridge temperatures are taken daily and controlled drugs are stored and documented correctly. The system is robust which reduces the risk of errors occurring. The manager undertakes medication audits and stock balances take place when new medication arrives. Service users have their privacy and dignity needs met. Staff were observed being respectful, friendly and professional, but at the same time they had an excellent rapport and banter which service users were observed enjoying. Comment card completed confirmed how much service users enjoyed living in this environment. No negative comments were received. Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 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): 12,13,14 & 15 Quality in this outcome area is good. Service users enjoy a range of activities and visitors and family are made welcome. Staff encourage autonomy and the meals provided are good. This judgement has been mad using available evidence including a visit to this service. EVIDENCE: Service users enjoy a range of activities, these include tea dances, entertainers, dominoes, one to one sessions, reading, and trips into Acomb. Though there is not a designated organiser, the care leaders decide who has daily responsibility for this. Service users social life and previous history is well documented and staff are clear as to who prefers which activities. Visitors were observed being welcomed into the home, drinks are always offered and meals can be provided. Links with the local community are forged through the church, local public house and community groups. Service users confirmed that they could get up and go to bed when they wished, and staff ask them when they would like a bath. Throughout the visit it was evident that service users are given choice on all aspects of daily life and are encouraged to be independent. Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 Page 12 The mealtimes were discussed in detail. The cook who only provides a proportion of the meals (the majority are provided through the local hospital) had an excellent understanding of the dietary needs of the service users. She cooks homemade food which service users commented positively on. Fish, chips and mushy peas was served at lunchtime which service users were observed enjoying. The portion sizes were good and some service users who did not ant the batter had the option of parsley sauce. The tables were laid with material cloths and napkins, glasses and pot crockery was offered and the whole atmosphere was pleasant and enjoyable. Service users spoken with stated how wonderful the home cooked food was. Comments regarding the hospital food were not as positive. Frozen vegetables are often served and the choice is not suitable for the client group. This should be reviewed to ensure the service users preferences are acted upon. The kitchen area was examined, this was clean and tidy with food being stored correctly. The cook had previously undertaken food hygiene training and was aware of how to ensure meals were nutritious and suitable for either diabetics, pureed diet or reducing diet. The cook knows the service users well and liases with the care staff to ensure their needs are being met. Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 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): 16 & 18 The quality outcome in this area is good. Service users live in a safe environment and have their views listened to and acted upon in a prompt manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home have a complaints procedure in place. Service users spoken with said they would discuss any concerns with any member of staff, they all felt their concerns would be listened to. No complaints have been made to the CSCI and the home does not have any outstanding complaints. Staff spoken with said they would feel confident that either one of the four care leaders or the manager would deal with any issues appropriately. Adult protection was discussed with the care leader, it was evident that she had a good understanding of the different types of abuse and was aware of the action to take if an allegation is made. The home follow the City of York Council vulnerable adults procedure. Staff have attended adult protection training, this was confirmed in discussions and through the training records. Staff are aware of how to make a POVA referral and the checks that take place prior to staff being employed. Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 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 & 26 Quality in this outcome area is good. Service users live in a clean smelling pleasant environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users commented positively on the environment, a plan of refurbishment has been taking place to develop the service further. The majority of the rooms are not ensuite, though many of the service users are mobile and therefore can access the toilet and bathing facilities. All areas inspected were clean and well maintained. The home have an infection control procedure and staff spoken with were aware of how this should be implemented. The laundry was examined and this had an adequate amount of washing and drying facilities. The laundry staff were aware of how to wash soiled linen and how to prevent cross infection. Staff receive infection control training which was documented. Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 27,28,29 & 30 Quality in this outcome area is good. Service users are cared for by skilled and competent staff who work in sufficient numbers to meet individual needs in a safe environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels in the home are good. There are currently fifteen service users and staff are able to meet their needs individually. Many positive comments were received from service users, including “staff are wonderful, kind and caring and just lovely”. This was echoed throughout the visit. The home have worked hard to achieve the target of 50 of care staff achieving an NVQ Level 2 in care. Staff spoken with were experienced and knowledgeable on caring for service users over 65. Service users best interests were clearly a priority for staff. The home have a robust recruitment procedure in place, this was discussed with the manager. Staff files were checked and CRB/POVA checks had taken place, two written references were obtained prior to employment and staff are aware they have an induction to complete. The induction process is being amended from the end of October. Staff will have to complete all their mandatory training within the first twelve weeks of their employment. The induction process is equivalent to Skills for Care. Staff confirmed all staff currently undertake induction training to ensure care practices are understood. A new deputy manager has been employed who will work some supernumerary hours alongside the current manager. Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 Page 16 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 & 38 Quality in this outcome area is good. The manager runs the home in the best interest of the service users, their money is safeguarded and their views and opinions are regularly sought. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users live in a well maintained home, run by an effective manager. The manager knows each individual and is keen to seek their views and opinions. The quality assurance system is being further developed in line with City of York Council Guidance. The manager has worked in a range of care settings and has applied to become the registered manager of Windsor House. Currently staff obtain views from service users through informal discussions, daily chats and one to one sessions. This is feasible at present as there are only fifteen service users. Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 Page 17 Service users finances were discussed, each service user is offered an individual wallet where a limited amount of money can be stored. Service users ask the administrator for their money when needed. Records confirmed transactions are made and clearly documented. Two service users finances were checked, these both tallied with the records. Service users confirmed they spend their money on hairdressing, chiropody, newspapers or clothes. Health and safety in the home was checked and discussed. The pre-inspection questionnaire provided information regarding testing of equipment, certificates and mandatory training. Staff have completed moving and handling, fire safety, infection control and some adult protection training. This was confirmed in individual staff files. The manager is in the process of developing a training matrix to ensure he has an overall picture of the training which has taken place and which training is due. One member of staff is responsible for taking monthly water temperatures, these were checked and found to be within expected parameters. Staff take the temperature of the water prior to service users having a full immersion bath. Fire drills take place weekly and emergency lighting and automatic fire doors are in place. The home have a lift in place which was fully operational and hoisting equipment was observed working well. No concerns were raised regarding health and safety and service users spoken with said they felt safe in the home. Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 Page 18 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 4 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x 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 2 x 3 x 3 x x 3 Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 Page 19 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. Standard Regulation Requirement Timescale for action 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. 2. Refer to Standard OP15 OP31 Good Practice Recommendations The City of York Council should review the standard of meals provided by the hospital. The manager should become registered with the CSCI as soon as possible. Windsor House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 House - City of York Council DS0000034926.V313794.R01.S.doc Version 5.2 Page 21 - 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. 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