Inspection on 29/09/05 for Windsor Nursing Home

This inspection was carried out on 29th September 2005.

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

The inspector found 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 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 Mrs P A Worley Announced Inspection 29th September 2005 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.V259865.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V259865.R01.S.doc Version 5.0 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.V259865.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th April 2005 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.V259865.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced, and was carried out by one Inspector over one day. Before the inspection a 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. A tour around the home to check the cleanliness, health and safety matters, and maintenance and decoration was carried out. The Inspector spoke with fifteen residents, four visiting relatives, and seven staff including the cook, and the Manager. The Inspector also had lunch with some residents in one of the two dining rooms. A number of records and documents were examined including residents’ care plans and staff files. An action plan had been received from the Provider following the last inspection and all but one of the two requirements fro that inspection have been completed. A review of standards looked at, at the last inspection was made and some additional standards were looked at during this visit. From this inspection, five requirements and one recommendation have been made. What the service does well: What has improved since the last inspection? From the recommendations made at the last inspection, the Manager has reviewed the use of the white plastic aprons, which are used to protect residents clothing from food spills. Cotton, patterned aprons of varying styles have been provided and residents can choose which type to use. Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 Page 6 Where residents are able to use small teapots, these are available for use at their dining table rather than have tea poured from a large communal teapot. The Proprietor has identified that the Home is in need of decoration and new furnishings and it is planned for this to be carried out by Christmas. 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.V259865.R01.S.doc Version 5.0 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.V259865.R01.S.doc Version 5.0 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-Intermediate care is not provided by the Home. Evidence of all appropriate assessments was not available therefore the Home cannot ensure that all residents’ needs’ can be met. EVIDENCE: The care plan files of two residents were inspected. Pre-admission assessments by the Home and assessments by the Home on admission were available, and the Home confirms in writing that it can meet the needs of the individuals’. However, there were no Care Management assessments or care plans available in either case. Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 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, 9, 10. Whilst residents appeared well cared for and stated that their health, personal and social needs were met, their individual care plan records still do not reflect all of their identified needs and how they are met. This therefore does not provide staff with adequate guidance as to what care is required and has the potential place residents at risk. Appropriate arrangements for the disposal of medicines are not in place, and unsafe administration practices, do not ensure the safety of medicines in the Home. Staff offer personal care and support to residents in a way that promotes and protects their privacy and dignity. EVIDENCE: Limited progress has been made on improving the care plan documentation to confirm that the personal and health care needs of residents are identified and met. Of the sample of care plans viewed there was no evidence of review since 2003 in one case, and evaluations were evident but in some cases record Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 Page 10 information that should lead to re-evaluation of care or the creation of new care plans to meet changed or new needs. A good range of health and risk assessment tools were available and completed but were not all dated or signed by the author. Three monthly audits of care plans are carried out but a limited number of records are audited to be effective. The Manager has arranged for training for nursing staff, provided through the Royal College of Nursing (RCN), in record keeping and care planning as an additional step towards addressing and improving the quality of care plan documentation. The arrangements for the ordering, receipt and storage and administration of medicines were satisfactory. However, the practice observed, of leaving the medicines trolley unlocked and unattended whilst administering medicines, is unsafe as any persons passing the trolley could gain unauthorised access to the medicines in the trolley. The Home does not have appropriate procedures in place for the disposal of medicines from the Home as required by the new legislation about the disposal of drugs in Nursing Homes. As the supplying pharmacy for the Home does not provide this service the Home must make suitable arrangements to contract with a company that does provide the service. The Home has received ‘quotes’ from some services for this but has not yet entered into a contract with any. The interim arrangements in the Home are not satisfactory as medicines are stored in a large plastic container which has a padlock in place and is kept in a locked room, however the plastic lid can easily be lifted allowing access to the medicines. The Home has obtained an appropriate container in which to ‘denature’ controlled drugs thereby making them safe, however they are also still kept in the Home. Observations of staff practice and conversations with residents confirmed that staff maintained their privacy and dignity. Staff knocked on doors before entering residents’ rooms, spoke politely to residents and generally treated them with respect in their dealings with them. Residents commented that staff were kind and friendly and some comments included: “the staff are lovely, so kind and friendly”, “they’ll do anything for you, I like them all” and “ they’re a good set of staff”. Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 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): 13 & 14. Arrangements to provide activities and social events and outings are good and residents are able to maintain links with family, friends and the community as they wish. Residents are able and supported by staff to make choices about how to spend their daily lives according to their wishes. EVIDENCE: Throughout the day, a number of relatives and visitors attended the Home. Some participated in the morning activities and spoke of the party scheduled for the afternoon for a residents whose birthday it was on the day. All residents were aware of the planned party and many spoke with enthusiasm about attending, some with their visitors who were to arrive in the afternoon. A strong sense of interaction and ‘kinship’ was evident in the Home throughout the day and residents and visitors said that it was always like this in the Home and that they were always made welcome, at any time of the day. Some residents spoke of trips out to places of interest and opportunities to stay with relatives and friends if they wished. Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 Page 12 A number of residents were spoken with and indicated that they decide how and with whom they spend their day. Evidence was seen of residents choosing where to sit in the lounge, meal choices, how and where to spend their afternoon and all those spoken with confirmed that they always made their own choices and staff respected this. Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 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 The Home has a satisfactory complaints procedure and system with evidence that residents feel that their views are listened to and acted upon. EVIDENCE: An appropriate complaints procedure is available and is made known to residents and relatives. Examination of the complaints records and conversation with the Manager indicated that there had been only one complaint received in the last twelve months. Residents and relatives who were asked said they were happy with the care received and did not have any complaints, but if they were unhappy about anything they would know what to do and who to speak to. Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 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 The environment of the Home is clean, safe and well maintained. The décor and furnishings are showing signs of wear and tear, which are to be renewed as part of the Home’s refurbishment and decoration plan. This will improve the image of the Home and provide residents with a more attractive and homely place to live. EVIDENCE: A tour of the premises was carried out and showed that the Home was clean to a good standard, odour free and generally well maintained. The environment is domestic in character and generally homely although the décor and furnishings are showing signs of wear and tear. The Provider has identified that the Home is in need of an ‘uplift’ with regard to decoration and soft furnishings. She has indicated that this is to be carried out in stages and is scheduled to be completed by Christmas. Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 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, 29 & 30. Staffing levels and skill mix are sufficient to effectively meet the needs of service users living in the Home. Procedures for the recruitment of staff are in place but not robust enough to provide the safeguards to offer protection to people living in the Home. Staff receive appropriate training in relation to the care needs of service users and to enable them to competently do their jobs. EVIDENCE: Discussions with the Manager and inspection of staff rotas indicated that appropriate numbers of staff are provided and maintained over the twenty-four hour period to meet the needs of the current residents. The Manager works supernumerary to the rota two days a week as a planned measure and on other occasions as necessary. A good level of ancillary/support staff are in post. Inspection of two staff files was carried out. One file confirmed that appropriate checks were carried out prior to the member of staff taking up post that included Criminal Records Bureau (CRB) and POVA register check, and two written references being obtained. However the second file revealed that the Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 Page 16 member of staff had commenced employment prior to the return and clearance of the CRB and POVA check. Evidence was seen of induction training for new staff. In discussions with the Manager and Deputy, and some staff in the Home it was confirmed that a good range of training has been provided. This has included all statutory training required and also a range of specialist and clinical training appropriate to individuals’ roles, such as challenging behaviour, care of the dying, communications and sight awareness. Good progress has been made with care staff training and NVQ qualifications at Levels 2 and 3, which exceeds the minimum level that need to be qualified. In conversation with some residents they said they felt safe living in the Home and were well cared for. Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 Page 17 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, 36 & 38. The Registered Manager is qualified and experienced to run the Home to meet its stated purpose, aims and objectives. The systems of quality assurance are not consistent or robust in monitoring the services provided by the Home and there is no formal system in place for the appropriate supervision of staff, in order to promote the best interests of the residents. The health, safety and welfare of service users and staff is promoted and protected through training and staff practices. EVIDENCE: The Manager is a Registered General Nurse and is appropriately experienced to run the Home. She has completed the Registered Managers award and the Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 Page 18 Deputy Manager is currently training for the NVQ level 4 and Registered Managers award. During discussions with the residents and relatives, they confirmed that the home was well managed and that they felt safe and supported by the staff team. A number of quality assurance measures to monitor the service are used, but do not form a structured system. Service user questionnaires are issued 1-2 yearly, and relatives’ questionnaires are being developed; no audits other than three monthly care plan and medications audits are carried out, staff meetings are held 1-2 a year and there have been no residents meetings held for some time. The systems should be more structured so that a specific development plan can be put in place for the continued quality assurance of the service. Policies and procedures for staff guidance, induction training and day to day contact is made with staff in order to monitor and support them. However, in discussions with a number of staff and the Manager it was confirmed that no system of formal supervision for staff has yet been implemented in the Home. Staff meetings do not take place regularly although an ‘open door’ policy of approach to the Manager is in place. The Deputy Manager has attended training on the subject of staff supervision and the Manager stated that a programme of formal supervision would be implemented in the near future. The Proprietors visit the Home regularly but the Proprietors monitoring visit reports to CSCI do not provide adequate continued information about the service within the Home. All staff receive training in health and safety, which includes moving and assisting, first aid, food hygiene, Control of Substances Hazardous to Health (COSHH), fire safety, infection control and risk management. Throughout the day staff demonstrated awareness of good health and safety practice. Moving and handling procedures by staff with the residents, were observed to be good with appropriate practices carried out. No hazards were identified at this inspection. Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 2 X 3 Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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. Service users care plans must be accurate and complete in order to identify their needs and how they are met. (Timescale of 31/7/05 not met). The Home must ensure the safety of medicines at all times and ensure that appropriate disposal arrangements are in place The Manager must ensure that all required checks are carried out prior to staff taking up posts, to ensure their fitness to work in the Home. A formal system of staff supervision must be implemented to ensure that the best interests of residents are maintained by staff. Timescale for action 30/10/05 2 OP7 15 31/12/05 3 OP9 13(2) 30/10/05 4 OP29 19 29/09/05 5 OP16 18(2) 31/12/05 Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33 Good Practice Recommendations More robust and effective quality assurance systems should be implemented in order to monitor the quality of care and service provided. Windsor Nursing Home DS0000000279.V259865.R01.S.doc Version 5.0 Page 22 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. 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