Inspection on 24/09/07 for Windsor House - City of York Council

This inspection was carried out on 24th September 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 - City of York... 13/10/06

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 Unannounced Inspection 09:30 24 September 2007 th 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.V333782.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.V333782.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 798004 01904 781828 mark.fox@york.gov.uk www.york.gov.uk City of York Council 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 Mark Vincent Fox Care Home 31 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (13) of places Windsor House - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP of the following age range: 65 years and over. Dementia - Code DE 2. 3. The maximum number of service users who can be accommodated is 31. To provide personal care and accommodation for up to 5 service users from the age of 55 years and over in the category DE. Date of last inspection 13th October 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 may have dementia. 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 is £432 per week, the standard charges through City of York Council. Information regarding the service is available in the statement of purpose and through previous inspection reports. Windsor House - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection took place on Monday 24th September 2007. Prior to the visit an annual quality assurance system was completed, and twelve surveys were sent to people using the service, their relatives, healthcare professionals and staff members. One inspector spent 5.5 hours completing the site visit. During this time observations of care practices took place, aspects of the environment were inspected, care plans and related medication documentation were examined and a range of people discussed the care they receive including the food and drink provided, the activities and the daily choices offered. Both the deputy manager and manager were available to assist during the visit. A discussion regarding the progress of the service since it started admitting people with dementia took place. Areas including health and safety, protection of individuals and staffing issues were all examined. The home is generally well run and care is given by dedicated staff in a pleasant environment. What the service does well: What has improved since the last inspection? What they could do better: Individual risk assessments need to be maintained and regularly updated. Windsor House - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 6 The medication system needs to be more robust to ensure people receive their prescribed medication. All mandatory training must be completed regularly, this specifically relates to fire training and infection control. This will help prevent people been put at risk of harm. 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 - City of York Council DS0000034926.V333782.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.V333782.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 (Standard 6 is not applicable). People who use the service experience good quality outcomes in this area. Needs are assessed in a comprehensive and detailed manner. This helps to ensure individual needs can be met. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home carries out comprehensive assessments prior to admission to the home. Most people have an initial care manager assessment which then helps to inform the homes assessment. Three assessments were inspected and these were detailed and informative. The manager involves the key worker with the assessment and tries to ensure this person is on duty when the new person comes to the home for the first time. Windsor House - City of York Council DS0000034926.V333782.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. People who use the service experience good quality outcomes in this area. Health and personal care needs are generally met, though improvements in risk assessments would help maintain this. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: Overall people’s health and personal care needs are met. The home now cares for people with dementia on two floors. People looked well cared for and details of the care given was available in individual care plans. Details regarding social needs, personal care and past history was available. Plans had been reviewed and evaluated on a regular basis. Risk assessments for the prevention of pressure sores, moving and handling, and the risk of falls were evident. On one occasion the assessment regarding pressure sores was completed inaccurately, and a moving and handling assessment was left blank. Currently nutritional assessments are not completed, although the documentation is now available. People have access to the chiropody, doctor Windsor House - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 10 and community mental health team, this is recorded in the care plan. A key worker system is in operation which means certain staff have responsibility for a group of individuals. The home is aware of how to record accidents and incidents through the Regulation 37 notification system. The medication system was inspected, generally this was satisfactory and people received the appropriate medication. However on some of the medication charts there were blanks where medication had been given but not signed for. Some medication for Parkinson’s disease was not always given or it was administered at different times, this needs to be reviewed. It would be beneficial having a formalised medication audit system to identify where the errors are. Fridge temperatures are taken and the controlled drugs are stored and recorded correctly. Staff are also aware of how to dispose of medication. Privacy and dignity in the home is maintained, people were observed being treated in a respectful manner and staff had a good rapport with people using the service and their relatives. It would be beneficial having more signs for people to identify where the nearest toilet is, or more pictorial information. Windsor House - City of York Council DS0000034926.V333782.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. People who use the service experience adequate quality outcomes in this area. People have access to some activities, autonomy and choice is encouraged and the food and drink provided is appropriate to this client group. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home is developing the activities offered. There is an activities book and some people have completed life profiles which discuss the persons social history/hobbies/interests prior to coming into the home. There is a newly landscaped garden and plans are in place to provide a sensory garden at the front of the home. People have been involved with cultivating herbs from seeds in a raised planter. Currently staff are involved with facilitating activities during the afternoon when they have time. The current client group have specialised needs and staff need more time to interact effectively with these individuals with dementia. Autonomy and choice is encouraged, and people are able to get up and go to bed when they choose and have their food and drink in either the dining area, own bedroom or one of the lounge areas. Windsor House - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 12 Visitors are welcomed and religious and cultural needs can be catered for when required. The home has two dining areas both of which are pleasant and attractively decorated. The lunchtime meal was examined on both floors and this was found to be relaxing and a pleasant experience for people. Staff helped people in a dignified manner and the food provided looked appetising, which people clearly enjoyed. The home are offering a trial in October where the main meal is served on an evening and a lighter meal will be offered at lunchtime. This was following comments from people using the service and staff. The food served is mainly provided through the local hospital. Staff offer a choice of food at each mealtime. At the site visit mince or chicken pie was offered with a mix of fresh and frozen vegetables, and for desert crumble and custard. The staff were aware of different portion sizes and the likes and dislikes of people. Windsor House - City of York Council DS0000034926.V333782.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. People who use the service experience good quality outcomes in this area. Concerns can be raised with the confidence that they will be acted upon effectively, and people are protected from harm. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The home have a complaints procedure in place which people were aware of. Surveys generally confirmed people using the service and their relatives know how to complain. During the visit three people spoken with said they would be happy to speak to a member of staff if they had any concerns. No complaints have been made since the last visit either via the home or through CSCI. People are protected from harm the local authority have a safeguarding adults procedure in place which the manager is aware of. Senior staff are now aware of the procedure to follow and whilst care staff have not routinely received abuse training, in discussions their knowledge of different types of abuse was good. People said they felt safe in the home and commented positively on the staff. Windsor House - City of York Council DS0000034926.V333782.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. People who use the service experience good quality outcomes in this area. People live in a safe and clean and pleasant environment. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: People enjoy living in the home. All areas inspected were clean and well maintained. The home have recently completed a refurbishment to ensure it is suitable for people with dementia. The environment has been made more secure to ensure people are not put at risk. The rear garden has been landscaped and plans are in place to develop the front garden. Any maintenance works which needs to be carried out is done through contractors employed by City of York Council. Windsor House - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 15 The laundry area was examined which was suitable to meet needs of people at the home. Sufficient washing and drying facilities were available and the deputy discussed the different skips and bags to use when dealing with soiled laundry. More staff need to complete infection control training to ensure people are not put at risk through cross contamination. This was evident when speaking with staff and when inspecting training records. Windsor House - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. People who use the service experience adequate quality outcomes in this area. Whilst people are cared for in sufficient numbers and recruited effectively, further training is needed to ensure people’s needs are consistently met. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: People in the home are cared for by dedicated staff who have a good rapport with people using the service. Currently there are enough staff. The manager is supernumerary and there is a deputy available. At the site visit a relief care leader was working with two care staff downstairs and two care staff upstairs, supported by general assistants. However, staff morale was low and staff discussed previous staff shortages and the lack of dementia training. Whilst there was some evidence of dementia training staff felt that specific training is needed to deal with people with challenging behaviour. The deputy who was in charge for two weeks has no experience of dealing with dementia care and the care leader at the visit has not undertaken any dementia training recently. Staff need to have the skills and knowledge to recognise the needs of individuals and understand how to manage behaviour effectively. The home has had difficulty recruiting staff which has had an effect on morale. Day and night staff need to have a greater understanding of each others role, as Windsor House - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 17 comments were made regarding the times people get up and go to bed. The home must ensure people have a choice and any issues regarding staff must not effect people using the service. Some staff have completed an NVQ level 2, and more staff are working towards this. All staff are recruited on an equal opportunities basis. Three recruitment files were checked, two written references are obtained, along with a police check and protection of vulnerable adults check. Human resources pass this information onto the home. All staff now complete the 12 week common induction standards, mandatory training should take place within this 12 weeks but this does not always happen. Staff spoken to confirmed they have received induction training. Windsor House - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 18 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 & 38. People who use the service experience good quality outcomes in this area. The home is generally run in the best interests of people, though some aspects of health and safety need improving. We have made this judgment using a range of evidence, including a visit to this service. EVIDENCE: The manager of the home is an experienced manager who is registered with CSCI and who has completed an NVQ Level 4 in management. Over the past 18 years the manager has gained skills and knowledge in caring for older people with personal care and dementia care needs. The manager has worked at Windsor House for over two years. Staff spoken to felt the manager was open and approachable, however some surveys commented that more support Windsor House - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 19 is needed towards the staff from the manager. this is partly due to the move towards caring for people with dementia. This was discussed with the manager. People using the service felt happy to discuss any issues with the manager and this was confirmed in the relatives surveys. The quality assurance system has improved and a statement has now been developed. However, further work is needed to ensure systems are audited effectively including care plans and medication. Some surveys have been sent out to people but this needs to be done in a structured way with a clear annual development plan as to how this process works and the action taken to comments made. Staff meetings take place and it was evident that staff regularly ask people their views and opinions regarding their well being. Finances are dealt with in the home effectively and a new audit system has been introduced to monitor this. Health and safety in the home was discussed. People feel safe in their environment and no hazards were identified during the site visit. A range of checks are in place regarding maintenance of equipment, this was evident in the annual quality assurance assessment i.e. electrical equipment, emergency call system and fire detection equipment. Water temperatures were checked and these were found to be within normal parameters. The home has not checked these for three months, this should be done more regularly. A discussion took place regarding fire safety. A risk assessment is in place and fire doors, emergency lighting and fire alarm testing takes place routinely. The home have a training matrix in place which is completed and updated by the deputy manager. Whilst this is beneficial this information had not be completed correctly. Some people were showing they had not received fire training since March 2004, or October 2005. No explanation was given for this from the deputy. However, the manager obtained information before the end of the visit which confirmed some staff have received this training and others are due to attend in November 2007. The home must keep staff updated with fire training and infection control and keep accurate records to reflect this. Windsor House - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 20 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 3 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 2 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 - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 21 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 OP9 Regulation 13 Requirement Prescribed medication must be recorded correctly on the medication charts. Staff must attend infection control training to ensure they are implementing up to date procedures. Timescale for action 25/09/07 2. OP26 13 24/11/07 3. OP38 23 Staff must have fire training on a 24/11/07 regular basis to ensure they know what action to take if a fire occurs. Evidence of this must be forwarded to CSCI. Windsor House - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 22 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. 3. Refer to Standard OP8 OP30 OP33 Good Practice Recommendations People’s nutritional needs should be appropriately assessed to ensure needs can be met. Staff need to ensure they have the appropriate training to care for people with dementia. Further development of the quality assurance system needs to take place to ensure views and opinions are sought from people using the service. A clear audit of the care plans and medication system needs to take place to ensure needs are being met. Water temperatures should be recorded on a monthly basis to ensure people are not put at risk of burns/scalds. 4. OP38 Windsor House - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 - City of York Council DS0000034926.V333782.R01.S.doc Version 5.2 Page 24 - 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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