Inspection on 27/07/06 for Windsor Nursing Home

This inspection was carried out on 27th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Windsor Nursing Home 19/06/08

Windsor Nursing Home 27/06/07

Windsor Nursing Home 29/09/05

Windsor Nursing Home 28/04/05

Windsor Nursing Home 29/10/04

Windsor Nursing Home 21/07/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Windsor Nursing Home Victoria Road East Hebburn Tyne And Wear NE31 1YQ Lead Inspector Mr Tom Moody Key Unannounced Inspection 27th July 2006 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 Nursing Home DS0000000279.V302939.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 Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windsor Nursing Home Address Victoria Road East Hebburn Tyne And Wear NE31 1YQ 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) 0191 4301100 Dr Inder Paul Vinayak Dr Veena Vinayak Mrs Marilyn Jackman Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42), Physical disability (2) of places Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service may from time to time admit persons under the age of 65 within the OP category 29th September 2005 Date of last inspection Brief Description of the Service: Windsor Nursing Home provides nursing care for people from the age of 55 years and over, and personal care, for up to 42 older people. The home is purpose built and has two floors, access between floors being with a passenger lift as well as stairs at either end of the building. There is easy access into the building and corridors and doorways are wide to accommodate wheelchairs. There is a lounge and dining room on each floor with a conservatory adjoining the rear of the ground floor lounge. The first floor lounge is the designated smoking lounge. There are 41 single rooms and 1 double room and all but one single room, have en-suite toilet facilities. The home is situated between the towns of Jarrow and Hebburn and is within easy access to the local town centres and shops, and also to public transport, local parks and many other amenities. Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced, and was carried out by one Inspector over one day in July 2006. Before the inspection a self-assessment questionnaire had been completed by the Manager, which gave up to date information about the home to allow more time to be spent with residents on the day of the inspection. A tour around the home to check the cleanliness, health and safety matters, and maintenance and decoration was carried out. The inspector spoke with residents, visiting relatives, and staff including the cook, and the Deputy Manager. The inspector did not have lunch with residents but observed the meal that was served in the two dining rooms. A number of records and documents were examined including residents’ care plans and staff files. What the service does well: What has improved since the last inspection? Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 6 There has been some improvement in the writing and completion of care plan. 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 Nursing Home DS0000000279.V302939.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 Nursing Home DS0000000279.V302939.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): 1,2,3,4,5 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users entering the home have some of their needs accurately assessed by social care and health service staff. The home makes it’s own assessment in addition to this but this could still be improved. Most service users and their family have the opportunity to visit the home before they come to stay, unless there are exceptional circumstances and accurate information is availale about the home. This allows them to make an informed choice about their stay. EVIDENCE: The deputy manager confirmed that relatives and service users can visit as often as they wish before deciding if they want to live in the home. The service users guide and statement of purpose is available at the entrance lobby. These are comprehensive and contains all relevant information. Service users did comment that their relatives were able to visit the home and make the decision for them to live there. Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 9 Service users contracts were seen and did contain necessary information. The care plans have improved and the assessment of service users needs was better than in earlier inspections. Some care goals were unrealistic (such as being safe at all times) Although physical needs were adressed the psychological needs of some service users did not seem to be recorded and staff had not considered some of these aspects of care. Some service users with communication difficulties did not have adequate strategies recorded although some care staff were able to explain how they could interpret none verbal communications. Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 10 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 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Service users physical health care needs are met but other areas may require attention. Service users have access to most of the healthcare services that they need. The home has appropriate policies and procedures to ensure service users receive their medication in a safe way but the storage facilities are not entirely approriate. EVIDENCE: The deputy manager confirmed that there is an appropriate system for disposal of unwanted drugs. The storage of medication is not as good as it could be. The clinical area is not properly ventilated and is too hot. The controlled drug storage does not meet professional guidlelines. A monitored dosage system is in use and recording is good. Stock balances are correctly kept. Care plans have been improved. Service user’s care plans contain much useful clinical information but this is rather scattered and it is difficult to get a Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 11 comprehensive picture e.g. weights are recorded in different areas and BMI charts are all but illegible. There is a record of visiting professionals in service users care plan . Some of the life histories were well recorded but psycological needs and communications strategies were not recorded. One service user had little interaction or communication of any kind although this had not always been so. Staff were unclear if he had had a recent psychiatric assessement and this was not clear from his care plan either. Some care goals were unrealistic, for example, to attempt to keep service users safe at all times is a very difficult task. The deputy manager has good awareness of service users clinical needs and some carers demonstrate a good awareness of service users needs, however this is not fully reflected in the care plans. Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 12 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. This judgment has been made using available evidence including a visit to this service. The homes staff provide a lifestyle that matches service users needs and preferences. Meals are of good quality and the timing and choice can be varied to meet service users needs. EVIDENCE: Staff deal with relatives appropriately,both in person, and in telephone enquiries and have a good relationship with famillies. This was confirmed by observation and discussion with service users relatives. The cook makes regular contact with service users to monitor satisfaction with the meals. The kitchen staff are keen and well motivated. Menus are satisfactory. The kitchen is clean, well organised and it is well equipped. The food was served at same time as medication were given. The inspector felt that this detracted from the dining experience and the staff group had to engage in two activities at the same time. Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 13 The quality and presentation of food was good. The kitchen staff have list of service users choices.Service users spoke favourably about the quality of food. Service users were supported in a suitable manner by most staff although one staff member was feeding someone from a standing position for a short while. Visiting is unrestricted and visitors were seen coming and going throughout the day. Several service users confirmed they were able to go into to the garden if the weather was suitable. A number of service users and visitors were using this facility. Staff adressed service users appropriately and they were enthusiastic about their role. Service users were taking part in small scale activities such as games of dominoes and were being supported by staff if this was necessary. Some staff display a good depth of knowledge of service users needs. All service users who were spoken to expressed positive views on the way they were looked after. Typical coments were, Im well looked after here, The staff are all very good. Relatives were equally complimentary about the care in the home, saying, Ive no complaints about the service here, “my brother is well looked after in here. and I can spend quality time with my mam. Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The home has appropriate policies and procedures and staff know how to use them. Service users and the majority of relatives are confident in the process and how staff will operate it. This should ensure the protection of service users. However the service cannot demonstrate effective auditing and responding to complaints because of the lack of recording of representations. EVIDENCE: According to the provider’s self assessment there have been no complaints since the last inspection. The previous inspection report also noted low levels of reporting. However this visit confirmed there were few recorded complaints. The few records are good. Nevertheless not all representations are recorded. Discussions with the deputy manager revealed that some relatives made regular representation to them but this was not recorded. It was suggested that relatives may be encouraged to record for themselves in the complaints and comments book. The deputy manager stated that there are relative groups meetings planned. The Deputy also stated the home had an open door policy. All relatives who were spoken to said that they found the staff helpful and felt that the manager was approachable. Staff spoke of having training in adult protection and had a good awareness of the issues surrounding this. Staff are scheduled to receive training in adult protection issues. Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 15 The home has suitable policies and procedures. Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The environment is routinely maintained but some areas still need attention. Similarly, the home has some good equipment but there are some areas that are deficient. Therefore, although the home is, in the main, safe, some hazards are present and need to be eliminated to ensure service user’s safety. EVIDENCE: The home’s self-assessment indicates regular maintenance is carried out and certificated. It is relatively modern and purpose built. It does have some design faults including lack of ventilation to the clinical room. The home has a sheltered and secure garden area that service users were able to use. Lounges had good levels of natural light and were well ventilated. Most service users bedrooms contained personal items and were pleasantly decorated. Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 17 Some of the bathrooms were less well decorated and several had damaged paintwork and in some cases damaged plaster. One bathroom was found to have a sink containing black liquid, presumably used to clean the wheelchairs that were stored there. The bath panels were damaged and the room was being used for storage. The deputy Matron confirmed this room was not usable for the majority of service users because it did not contain a hoist. Many bathrooms, toilets and other communal areas had low light levels. This was mainly due to the use of low wattage bulbs, often combined with poorly designed shades, potentially putting service users at risk of falls or disorientation. This was brought to the deputys attention on the day , however higher wattage bulbs were not readily available. Fire precautions were observed by staff. The extract ventilation in one sluice area was inadequate and there was odour in this room. This was brought to the deputy managers attention. There was no evidence of a loop system being available for hearing aid users. The home was kept clean in most areas and there were no unpleasant odours detected in areas occupied by service users. Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 18 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. This judgment has been made using available evidence including a visit to this service. The home operates safely and sufficient numbers of staff, who are appropriately trained, are available to meet service users needs. EVIDENCE: The recruitment records seen at this inspection indicated that practice had improved. All necessary checks have been carried out. There is documentary evidence of staff training, and staff confirmed that they receive good induction and support. Staff members were wearing badges that indicated they had attained NVQ qualifications. The duty rotas indicated a satisfactory level of staffing was available . Staff did not appear to be unduly pressured on the day of the inspection and the call system was answered promptly. Service users and their relatives comments showed they were satisfied with the way they were looked after. Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 19 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): 32, 33, 35 36, 38 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The manager is professional in her approach and service users benefit from the way she carries out her duties. The service needs further support, and resource, from the registered owners to ensure the home provides a safe and suitable environment for service users and staff. EVIDENCE: The manager was not in the home at the time of the inspection. She is a registered nurse of some years experience. The deputy manager was in charge. Most of the systems in the home were safe, apart from the low light levels. Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 20 Risk assessments were carried out but the manager should ensure realistic goals are being set. Service users and their relatives spoke of staff and managers being approachable and all of them indicated they could take problems to the manager. Although most were quick to point out they were satisfied with the home. Supervision was not being regularly carried out. The deputy did point out that appraisal systems were in place and examples of these were seen. Discussions with the deputy revealed there was little commitment to the idea of regular supervision, although it took place on an informal basis during daily contact with staff. The inspector had a long discussion about the merits of supervision and it was suggested that the homes management may wish to research the idea further. Discussions with the staff revealed thay are well motivated and enthusiastic about their job. The deputy spoke of the manager looking at a quality assurance system. Two large ring binderrs were produced as evidence of this. It was agreed that this was unweildy and not well understood by anyone in the home. It was suggested that a simpler system should be adopted. Service users financial records were seen and the system is fairly robust. Receipts are kept and balances are checked regularly, by two people, but it was recommended that both signed for this. Accumulated balances are placed in a poooled account and this is not in line with national minimum standards, even though it is not interest bearing. . Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 21 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 2 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 17 x 18 3 2 2 2 2 3 3 2 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 x 2 3 x 3 2 x 2 Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 14 Requirement Assessments carried out by appropriate persons must be available to confirm that service users needs’ can be met. (This is an outstanding requirement from the previous report.) Service users care plans must be accurate and complete in order to identify their needs and how they are met. (This is an outstanding requirement from the previous report) Timescale for action 11/09/06 2. OP7 15 11/09/06 3. 4. OP9 OP19 13 (2) 23(2)(d) 23(2)(b) The Home must ensure the safe 28/08/06 storage of medicines at all times. All areas of the home used by service users must be adequately decorated and maintained. 09/10/06 5 OP21 23(1)(a) 23(2)(c) 23(2)(j) 23(2)(p) 13(4)(a) 6 OP25 Adequate number of bathing 11/09/06 facilities, suitable to meet service user’s needs, must be maintained in the home. Light levels must be maintained 28/08/06 to the levels set out in the DS0000000279.V302939.R01.S.doc Version 5.2 Page 23 Windsor Nursing Home 7 OP22 (c) 23(1)(a) 23(2)(n) 8 OP26 16(2)(k) 23(2)(b) 18(2) 21(2) 9 OP36 10 OP33 24(1)(a) 12(5)(a) (b) 12(1) (a) 13(4)(a) (c) 11 OP32 12 OP38 12(1) (a) 13(4)(a) (c) National Minimum Standards. The home must provide equipment, such as loop induction systems and suitable bathing facilities, to meet the assessed needs of service users. The home must have suitable ventilation system in all areas and this must be maintained in working order. A formal system of staff supervision must be implemented. (This is an outstanding requirement from the previous report.) The home must introduce a quality assurance system to monitor their own performance and allow customer feedback. The home should be conducted with the welfare of service users in mind. For example low wattage light bulbs result in a care environment that may affect the health and safety of staff and service users. The home should be conducted with the welfare of service users in mind. For example low wattage light bulbs result in a care environment that may affect the health and safety of staff and service users. 11/09/06 11/09/06 11/09/06 11/09/06 28/08/06 28/08/06 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 OP33 Good Practice Recommendations More robust and effective quality assurance systems should be implemented in order to monitor the quality of DS0000000279.V302939.R01.S.doc Version 5.2 Page 24 Windsor Nursing Home care and service provided. Windsor Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Nursing Home DS0000000279.V302939.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!