Inspection on 27/02/06 for Windward Court Residential Home

This inspection was carried out on 27th February 2006.

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

Windward Court Residential Home 30/09/08

Windward Court Residential Home 05/10/06

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Windward Retirement Home Totnes Road South Brent Devon TQ10 9JN Lead Inspector Graham Thomas Announced Inspection 27th February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 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. Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Windward Retirement Home Address Totnes Road South Brent Devon TQ10 9JN 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) 01364 72386 Thurlestone Court Limited Mrs Geraldine Maria Swift Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20), Physical disability over 65 years of age of places (20) Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection First inspection since new registration on 01/11/05 Brief Description of the Service: Thurleston Court Ltd. took ownership of the home on 1st November 2005 and registered as Providers. Ms. Brigitte Harvey is the Responsible Individual. The home is now part of a group of loosely affiliated companies and partnerships collectively known as “The Court Group”. This group has a number of homes in the Torbay and South Hams areas of Devon and promotes a corporate identity and ethos. Windward House is a detached property set in its own grounds in the village of South Brent. The home currently provides care for up to 20 older people some of whom may have a physical disability and mobility problems. Accommodation for residents is provided on two floors in mainly single rooms with en-suite facilities. A stair lift operates between the two floors. Also part of the home is a separate unit providing two semi-independent apartments. At the time of this inspection, part of a substantial extension to the home was in an advanced stage of construction. This forms part of a planned extension and refurbishment which will upgrade existing accommodation and provide additional places. Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the inspection, a pre-inspection questionnaire completed by the Registered Manager was reviewed. Feedback cards completed by service users and relatives / visitors were also examined. During the inspection the Inspector spoke with ten service users, two care staff and the home’s cook. Discussions were held with Ms. Geraldine Swift, the Registered Manager and Ms. Brigitte Harvey, Responsible individual. During the inspection a visiting GP spoke with the Inspector. A sample of records was examined including care plans, staff records and other documents. The premises were inspected and the system for administering medicines was examined. What the service does well: What has improved since the last inspection? What they could do better: Current guidance on recruitment practices must be followed, particularly with regard to obtaining checks against the Protection of Vulnerable Adults (POVA) register. Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 Page 6 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. Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 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 Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 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 and 6 The needs of prospective service users are properly assessed prior to admission and they are appropriately assured that these can be met. EVIDENCE: The care plan of the most recently admitted service user included a detailed pre-admission assessment. This admission had taken place over a protracted period and had included visits to the service user in her own home and visits from her to Windward. Correspondence was also seen concerning her admission. Windward Court does not provide intermediate care. Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 The health and personal care needs are well met by the home. EVIDENCE: All service users have individual plans of care, a sample of which was inspected. These all included care planning documents, risk assessments and notes regarding medical consultations. The care plans showed details of needs in respect of personal care, healthcare, social, emotional needs and family contact. A key worker system is in operation in the home and individual key workers confirmed their responsibility for reviewing the care plans with service users. The review of the plans was also confirmed by the signatures of service users. Individual plans showed evidence of consultation with GPs, Opticians, District Nurses, Chiropodists, Dentists and other health professionals. Service users confirmed that they received prompt medical attention when required. One service user was awaiting an operation at the time of the inspection. A visiting GP confirmed that healthcare needs were well met by the home. She confirmed that service users’ health needs were adequately monitored by staff and that prompt referrals were made where health difficulties arose. Care plans showed Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 Page 10 that the Community Mental Health Team were appropriately involved with individual service users. Continence and dietary issues were detailed in the care plans and the daily activities programme included exercise sessions. The home’s system for administering medicines was examined. A monitored dosage system is in use, the records for which were up to date and in good order. A risk assessment was in place for one service user who self-medicates. The medicines are stored in a locked cabinet and cupboard. Although no controlled drugs were in use, storage was available with additional security and a controlled drugs register was seen. Staff confirmed recent training by the local Pharmacist. Homely remedies were in use and an approved list had been obtained. All those service users with whom the Inspector spoke felt that their dignity was upheld and that staff treated them with respect. This was further confirmed by observations during the inspection of interactions between staff and service users. Some service users have their own phones in their rooms and a mobile payphone is available for those who do not. Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 - 15 Service users are adequately supported to maintain choice and independence in pursuing their individual lifestyles. EVIDENCE: A programme of daily activities is organised by the home’s staff which service users may join or not, as they wish. On the day of inspection, a quiz was taking place. Other activities advertised on the notice board included bingo, lounge quoits, exercise, matinee afternoons and group reading. A minibus is available for group trips for which service users pay an additional charge. Some service users stated that they had trips out with friends and relatives while others were able to leave the home independently. Individual religious observance is documented and respected and communion services are held in the home. Feedback from visitors confirmed that they are able to meet service users in private. Service users confirmed that their visitors were made welcome to the home and offered refreshments. The visiting arrangements were said to be flexible. The Responsible Individual stated that the home’s newsletter was being remodelled to include circulation to staff, service users and relatives. Other plans were being considered to promote the involvement of relatives. Service users confirmed that they could decline to admit visitors they did not wish to see. Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 Page 12 The registered Manager was able to identify ways in which independence is promoted. One service, user, for example, is supported to continue administering her own medication. Independent professional advisors are involved, where required, in administering individual financial affairs. Information is available in respect of advocacy for service users and their families. Care plans are regularly reviewed with service users. Service users are able to bring personal possessions to the home including items of furniture should they wish. Individual dietary needs and preferences are identified in care plans. Dietary monitoring is conducted where this is required. The home’s six week rolling menu was discussed with the home’s cook. This includes a daily choices. On the day of inspection, the lunchtime choice included cottage pie or chicken goujons. On the whole, service users were satisfied with meals in the home. The cook stated that ideas for changes to the menu were to be discussed at a forthcoming residents’ meeting. Meals are taken in the home’s dining room in a pleasant and congenial atmosphere. Assistance is offered by staff where required. Those service users who wish to eat alone are able to exercise this choice. Service users are offered regular drinks and jugs of water were seen in individual rooms. Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 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 and 18 Service users and their visitors can feel confident that their concerns / complaints will be addressed appropriately. Commendably robust systems are in place to protect service users from abuse. EVIDENCE: Thurlestone court Ltd. has a complaints policy and procedure. At the time of inspection, one complaint had been received. This was recorded in the home’s complaints log, a response had been made to the complainant and action taken to address the difficulty identified in the complaint. Awareness training is provided for staff concerning the abuse of vulnerable adults. Policies and procedures are in place. Evidence from recent events has demonstrated that the Registered Manager has a well-developed understanding of abuse issues and acts in a commendably robust way to protect the interests of service users. Service users’ financial affairs are handled by relatives or professional advocates. Small amounts of money are securely stored for service users in the home. Receipts are kept and any transactions recorded. These records were sampled and found to be in good order. Policy statements preclude staff from gaining financial benefit from service users. Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 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): Service users live in a generally safe, clean, homely and well maintained environment. EVIDENCE: Accommodation for residents is provided on two floors in mainly single rooms with en-suite facilities. A stair lift operates between the two floors. Also part of the home is a separate unit providing two semi-independent apartments. At the time of this inspection, part of a substantial extension to the home was in an advanced stage of construction. This forms part of a planned extension and refurbishment which will upgrade existing accommodation and provide additional places. The need for some minor repairs and refurbishment were identified during a tour of the building. However, these will be addressed as part of the major works currently being undertaken. Documents examined during the inspection showed routine maintenance of the stair lift, gas and electrical safety checks and maintenance. Policies and procedures are in place to control the risk of infection. Infection control measures such as the wearing of gloves and aprons was seen during Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 Page 15 the inspection. There is a system for the disposal of infected waste. The staff training programme includes infection control. The home’s staff are commended for the particularly effective measures in place to control unpleasant odours. Laundry facilities are sited in a room with cleanable walls and impermeable flooring. The home’s washing machine has a sluicing facility and cycles suitable for laundering heavily soiled items. Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 Service users are supported by adequate numbers of staff who receive training appropriate to their roles. Current recruitment practices do not provide sufficient safeguards for service users. EVIDENCE: Staff rotas have been reorganised since Thurlestone Court Ltd. took ownership of the home. The responsible individual stated that the use of agency staff had now been eliminated, thus providing more consistency for service users. The general pattern of staffing provides two three carers in the morning, two in the afternoon and evening and two overnight, one of whom remains awake. The Registered Manager also provides caring support as part of her duties during the day. In addition, there is a cleaner and a cook. The most recently recruited staff member had completed an application and provided references. The member of staff was a previous employee and known to the Registered Manager. A criminal records check had been applied for but neither this nor a check of the Protection of Vulnerable Adults (POVA) register had been completed at the time of inspection. Of the current seven care staff, for hold an NVQ qualification at level 2 or above. Others are undertaking qualifying courses. New staff undertake an induction which is compatible with national training standards. The Court Group operates an internal training programme which includes health and safety topics. In discussion, staff confirmed they had received training in topics relevant to their work and the needs of service users. This included, for example, health and safety, first aid and continence training. Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 Page 17 Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Windward is generally well managed for the benefit of service users. EVIDENCE: The Registered Manager has completed an NVQ level 4 / Registered Managers’ Award and attends short courses to update her knowledge. She has a number of years experience in running the home prior to the recent change in registration. Staff and service users were clear about lines of accountability in the home. The Registered Manager demonstrated a clear understanding of her role and a commitment to meeting the National Minimum Standards. She has demonstrated diligence in rectifying any shortfalls identified during inspections and other internal processes. A quality assurance process has been developed for the home. This includes regular visits to the home by the Responsible Individual who provides reports on these visits to the Commission. The results of a recent survey of service Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 Page 19 users had been summarised and were available for staff and service users. Regular meetings are held for both staff and service users. There was evidence that ideas and suggestions from these meetings had been implemented. The Responsible Individual discussed with the Inspector plans to promote further the involvement of service users families in the life of the home. Service users’ financial affairs are handled by relatives or professional advocates. Small amounts of money are securely stored for service users in the home. Receipts are kept and any transactions recorded. These records were sampled and found to be in good order. As described above, staff receive training in health and safety topics such as fire safety, moving and handling, first aid and food hygiene. Hazardous substances are securely stored in a locked cupboard and data sheets are kept for staff reference. Records were seen of maintenance of the stair lift as well as gas and electrical testing. Risk assessments were in place both for individuals and environmental risks. Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 X X X X X X 4 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 3 X 3 X X 3 Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Not Applicable 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 OP29 Regulation 19 Requirement The Registered Manager must obtain POVA check for all new members of staff prior to appointment. Where staff commence employment prior to the completion of a CRB check, They must not have unsupervised access to service users in or out of the premises. A named supervisor must me identified for each shift until the CRB check is obtained. Timescale for action 07/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Windward Retirement Home DS0000065813.V276020.R01.S.doc Version 5.1 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. 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