Inspection on 28/04/05 for Windsor Nursing Home

This inspection was carried out on 28th April 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Windsor Nursing Home 19/06/08

Windsor Nursing Home 27/06/07

Windsor Nursing Home 27/07/06

Windsor Nursing Home 29/09/05

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 Mrs P A Worley Unannounced 28 April 2005 10:00am 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 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 B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Windsor Nursing Home Address Victoria Road East Hebburn Tyne and Wear NE31 1YQ 0191 4301100 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Dr Inder Paul Vinayak Mrs Marilyn Jackman Care home with nursing 42 Category(ies) of OP Old age (42) registration, with number PD Physical disability (2) of places Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 29th October 2004 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 B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 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 at the time chosen in order to observe practices and procedures during the day. The inspection process consisted of a tour of the building to check the cleanliness, some maintenance areas, decoration and equipment. The Inspector spoke with staff, service users and visiting relatives and made observations of staff practices throughout the visit, and also joined residents for the lunchtime meal in the first floor dining room. During the inspection ten residents, seven relatives and ten staff, including the Deputy Manager, were spoken with. A number of records and documents were examined including residents’ care plans, staff training files, records of monies held for residents by the home, and some maintenance records. Fourteen of the thirty eight National Minimum Standards (NMS) for Older People were assessed during this inspection, nine of those were from the nineteen key standards and four of those assessed were standards not met at the last inspection. An action plan was received from the last inspection to confirm how and when matters that required attention, and any recommendations made, were to be dealt with. Only one area still requires further attention and is stated in the last section of this summary. What the service does well: The Home provides a good and consistent level of activities, social events and outings, which encourages the participation of visitors and staff. Residents and relatives spoke well of the facility and the Activity Co-ordinators’ commitment to providing the service. Comments made to the Inspector by a relative and a resident included, “one reason my mother came here was because we knew she could continue with her social life and have her social needs met”, “we play a variety of games, do crafts and quizzes, why don’t you join us”. The Home has a friendly and homely atmosphere and all visitors to the home are made welcome and treated in a courteous manner and with respect by the staff. Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 Page 6 The meals are of ‘home style’ cooking and residents made such comments as “meals are just the job”, “ food’s good and there’s always plenty”, and “I like the food and there’s always cups of tea for residents and visitors”. 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 Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 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 standard(s) 3 & 4. Standard 6 does not apply as intermediate care is not provided by the Home. Appropriate assessments of residents’ needs are carried out prior to and on admission, in order to establish and ensure that the Home meets their needs. EVIDENCE: The service user care plan records examined showed that assessments by Care Management and the Home’s staff are carried out before admission and this identified that residents needs could be met at the Home. Evidence of other relevant assessments by suitably qualified persons, were also seen, for example physiotherapist and Nurse Specialist. In discussions with staff and observation of practices, they demonstrated a good awareness of individuals’ needs. Residents and their relatives comments included ”the girls are so lovely to me, I’ve never felt better”, “ everything’s good in here, staff are wonderful, very helpful”, “ staff are helpful and friendly and I’m well looked after”, and observations of care practice and interactions between residents and staff, it was clear that residents’ needs were generally being met. Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 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 standard(s) 7 & 8 Whilst service users appeared well cared for and stated that their health, personal and social needs were met, the individual plans of care records, which each resident has, do not adequately reflect the health, personal and social care needs and how they are met. EVIDENCE: Little progress has been made since the last inspection to improve the quality of documentation to ensure that all aspects of health, personal and social care needs are identified and planned for. This is despite the Manager having assured in the action plan that a more robust audit of care plans was underway. A good range of health and risk assessment tools are available but a number were incomplete, were not dated or signed and were not up to date. Instructions for care delivery in some cases used inappropriate statements such as ‘use appropriate pressure relieving aids’, but did not state which ones, ‘bedrails are the best method of ensuring safety’, but no statement as to why or how. Evaluations were evident but not all were up to date. Some residents care needs were described by their relatives but were not recorded in the care plans and some spoke of needs that were being met but were not identified or Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 Page 10 documented in the records. Residents are at risk of not having their health care needs met if accurate documentation is not provided for staff guidance, and as the evidence of appropriate care delivery. Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 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 standard(s) 12 & 15 Social and recreational activities are well provided for and provide daily variation and interest for residents to suit their preferences, expectations and needs. The meals are served in bright pleasant surroundings, are varied in their choices and are nutritionally balanced. The Home needs to review the use of communal teapots in order to maximise individuals’ independence. EVIDENCE: A programme of daily activities and planned events is displayed in the home. An Activity Co-ordinator is in post and throughout the day demonstrated a keen commitment to ensuring a good level of stimulation and activity was provided for residents, with participation from all who wished to, including visitors, encouraged. Residents and relatives who spoke with the Inspector commented that she was very good and made such comments as “she’s so good, always has something on”, “ she takes us out, I’m going to see a musical tonight”, and “ we miss ***** (the previous co-ordinator) but this one’s good”. A number of people who were spoken with stated that the meals were good and there were plenty choices. They also confirmed that their individual likes and dislikes were known by the staff and catered for. The lunchtime meal was Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 Page 12 very tasty, well presented and appetising. Many variations of choices were seen in portion sizes and presentations to suit individuals. Staff who assisted residents did so in a sensitive and courteous manner. The tables were pleasantly set with condiments, serviettes and a decoration, but the use of a communal teapot and milk jug deterred from the homely environment. There were some residents who were able to serve themselves from individual or smaller teapots, and the issue of enabling them to preserve that level of independence by providing these, was discussed. White plastic aprons, as a form of protection from food spillage, were offered and provided for all residents. Two residents commented that they liked to have protection for their clothes but would rather have something different as the food slides off the plastic onto their feet or the floor. This was observed to happen in some cases, and also the appearance of plastic aprons on adults somewhat compromises their dignity. It was suggested that an alternative protective cover be considered. Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 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 standard(s) 18 Through the Home’s Protection of Vulnerable Adults Policy and procedure and staff training, service users are protected from abuse. EVIDENCE: A policy and procedure is available to guide staff in the Protection of Vulnerable Adults (POVA), also a policy on whistle blowing, and is based on the Department of Health guidance. The Home also has a copy of the Local Authority procedures for their area. Staff who were asked confirmed that they had received training in the protection of vulnerable adults and were able to describe actions to be taken where allegations of abuse were suspected or witnessed. Care staff undertaking NVQ training confirmed that this subject is also covered during that training. A recruitment policy and procedure is available in the Home to ensure that unsuitable persons are not employed in the home. The storage of service users monies and financial records were seen and were secure. Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 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 standard(s) 19,22 & 25 The environment of the Home is clean, safe, well maintained and decorated, and appropriate furnishings and equipment are provided for residents’ safety and comfort. EVIDENCE: The Home was clean and free from offensive odours throughout. The maintenance items identified at the last inspection have been addressed and the provision of self-closure devices on the communal room fire doors now ensures safety in allowing those doors to remain open for operational purposes. Some areas have been re-decorated since the last inspection and a programme is in place for the continued maintenance of the Home. The records to confirm that regular maintenance and appropriate checks are carried out such as checking water temperatures and fire systems were seen, and were satisfactory. Appropriate and adequate equipment and adaptations are provided for residents to assist them in the independence and mobility. These include grab rails throughout the Home, assisted toilets and baths, mechanical hoists, Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 Page 15 variable height chairs and wide doors and corridors. Call systems are provided in all resident areas. Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 28 The numbers and skill mix of staff are generally satisfactory to meet residents needs but all occasions where staff need to leave the Home must be covered to ensure minimum and appropriate staffing is provided. Residents are supported and are in safe hands at all times as staff have the appropriate qualifications and training. EVIDENCE: Examination of the staffing rotas showed that staffing numbers and skill mix are generally maintained at acceptable levels, with the Manager having three days supernumerary to the nursing staff to carry out management functions, and this also applied for the Deputy Manager whilst the Manager was on leave. However, at the beginning of the inspection the Deputy Manager needed to leave the Home for a period of time to attend a service user review and a replacement nurse could not be found to cover. This was a previously known appointment and cover should have been planned for in advance. Forthcoming rotas showed some gaps where care staff cover was needed, and the Deputy gave assurance that these would be filled before commencement of that duty week. Good progress has been made with care staff NVQ training and qualifications. Seventy three per cent of care staff have NVQ qualifications and the remainder are scheduled to complete the training in the near future. Some of the ancillary staff have NVQ qualifications in housekeeping, which is good. In conversations with residents they stated that the staff were caring and kind and that they felt safe with them. Some said “ they’ll do anything for you”, “ they are always Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 Page 17 there for you” “they’re wonderful”. Interactions between staff and residents were friendly and respectful. A number of staff have worked at the Home for many years and provide consistency and continuity of care. A new member of staff indicated being comfortable and able to approach any member of staff for support and guidance and said that every one had been helpful. Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 & 38 Service users financial interests are safely handled and protected through the systems in place. The health, safety and welfare of residents and staff are promoted and safeguarded through training of staff and appropriate procedures and practices being carried out. EVIDENCE: Service users monies held in the bank are in their own name or an interest free account in the name of the service users. The recording and storage systems for residents’ monies and valuables are secure and well kept. Action has been taken since the last inspection regarding the provision of correct labelling and containers for domestic chemicals used in the Home. This was confirmed by domestic staff and also seen during the inspection visit. Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 Page 19 During the inspection all practices and procedures that were seen were carried out by staff appropriately and did not compromise the health and safety of the residents. Two events of staff transferring a resident between armchair and wheelchair using a mechanical hoist were carried out using good and safe procedure including informing the residents of what actions they would take. All staff confirmed that they had had training in moving and handling and this was evident in their good practice. In one service’s bedroom where oxygen was in use, it was advised that a notice to that effect should be available outside the room to inform people of the higher risk in the event of a fire. Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 4 COMPLAINTS AND PROTECTION 3 x x 3 x x 3 x STAFFING Standard No Score 27 2 28 4 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x 3 x x 3 Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 Page 21 yes 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 7 Regulation 15 Requirement Service users care plans must be in sufficient detail to provide information and guidance for staff on the actions to be taken to meet health and welfare needs. Care plans must be complete, accurate and up to date. (Timescale of 31/12/04 not met). Staffing numbers and skill mix must be maintained at minimum levels to meet service users needs at all times. Timescale for action 31st July 2005 2. 27 18(1)(a) 28th April 2005 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 15 15 Good Practice Recommendations The Manager should review the use communal teapots and consider smaller pots for each dining table as appropriate. The Manager should consider alternative protection for residents clothes from food splliage. Windsor Nursing Home B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 B52 B02 S279 Windsor Nursing Home V219274 28 Ap 05 Stage 4.doc Version 1.30 Page 23 - 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!