Care Home: Windle Court

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What the care home does well Windle court is a newly opened home, which has been furnished to a high standard. Residents` bedrooms were nicely decorated and personalised with their belongings. The new Manager has put systems in place to help ensure a good standard of care is provided to those people who presently use the service. There was a good atmosphere within the home and staff members were observed treating residents in a respectful and supportive manner. Although some updates were required, the staff had been provided with training to ensure they had the knowledge and understanding of their role as a carer. Supervision and regular support had also been offered to staff.Windle CourtDS0000073191.V375265.R01.S.docVersion 5.2 What has improved since the last inspection? Not applicable due to being first inspection. What the care home could do better: Generally the home is well run. It was apparent that a lot of work has been completed over the last six months to ensure the home meets with the National Minimum Standards and Regulations. No requirements were made at this inspection. Some areas that need to be developed included activities. There was a mixed response received from the present residents regarding the activities on offer within the home. Activities should be individual to each resident and look at past history and interests. Training was very good, but there were a few staff who were still waiting for safeguarding and also infection control training. Key inspection report CARE HOMES FOR OLDER PEOPLE Windle Court The Withywindle South Woodham Ferrers Essex CM3 7BB Lead Inspector Mrs Sharon Lacey Key Unannounced Inspection 12th May 2009 09:45 DS0000073191.V375265.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windle Court Address The Withywindle South Woodham Ferrers Essex CM3 7BB 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) 01702 559797 www.runwoodhomecare.com Runwood Homes Plc Vacant Care Home 76 Category(ies) of Dementia (76), Old age, not falling within any registration, with number other category (76) of places Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: either whose primary care needs on admission to the home are within the following categories: Old age, not falling into any other category - Code OP Dementia -Code DE The maximum number of service users who can be accommodated is: 76 New Service. 2. Date of last inspection Brief Description of the Service: Windle Court is purpose built home, which has been open for approximately 6 months. It is registered to provide care and accommodation for 76 older people, who have nursing or dementia needs. At present the home is concentrating on admitting those residents who have dementia or need assistance due to old age. Windle Court is a 2-storey building and is fairly close to local shops and community amenities. All bedrooms are single occupancy and have ensuite facilities. The home has a small courtyard patio area with raised flower beds. There are adequate parking facilities to the front of the home. The charges for Windle Court range from £450.00 to £650.00, depending on the care required and room facilities. This information was correct at the time this Annual Service Review was written. Residents are responsible for paying extra charges for external services such as chiropody, hairdressing, toiletries and newspapers. Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two (2) stars. This means the people who use this service experience good quality outcomes. This was a routine Unannounced Inspection, which took place over six hours. The Key Standards were inspected, but also evidence was gained on some of the other National Minimum Standards. A tour of the home was completed and an inspection of relevant records and documentation took place. Areas looked at included information given to residents before being admitted to Windle Court; information gained when residents first come into the home; how information is given to staff on the care required; the facilities and environment of the home; and any complaints that may have been received since the last inspection. Also staffing and management of the home were inspected. During the tour of the home some of the residents were spoken to about their life and experiences at Windle Court. Some of the other residents approached were unable to express their thoughts and feelings, but were observed during the day interacting with staff. Most staff members were spoken with informally during the Inspection and any feedback has been included as part of the report. Completed questionnaires were received from eight residents. Staff questionnaires were also distributed and four were received back. At the end of the day the Inspection was discussed with the Manager and advice and guidance was given regarding the findings. What the service does well: Windle court is a newly opened home, which has been furnished to a high standard. Residents’ bedrooms were nicely decorated and personalised with their belongings. The new Manager has put systems in place to help ensure a good standard of care is provided to those people who presently use the service. There was a good atmosphere within the home and staff members were observed treating residents in a respectful and supportive manner. Although some updates were required, the staff had been provided with training to ensure they had the knowledge and understanding of their role as a carer. Supervision and regular support had also been offered to staff. Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Windle Court DS0000073191.V375265.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 Windle Court DS0000073191.V375265.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Perspective residents can be sure that they will be provided with up to date information about the home and the services it provides. They can also be sure that an assessment will take place to ensure their needs can be met. EVIDENCE: Windle Court has been open for approximately 6 months and on the day of the inspection had 44 residents, but is registered to care for 76. They are registered to provide nursing care, but on discussion with the Manager she advised that they had since changed this and now intended to use the whole home to provide care for older people or those who may have dementia. It was established that they are presently looking at using one of the wings in the home to provide care for those people with challenging behaviour. Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 9 There are detailed operational policies to help with the day-to-day running of the home. The Statement of Purpose and Service User Guide had recently been reviewed and contained details of the home and the services provided. A copy of these documents could be found in the home’s foyer and the Manager confirmed that both new and prospective residents would be provided with copies during the assessment process. Feedback from the resident questionnaires indicated that they had received sufficient information about the home before moving in. Comments included everyone was very helpful and informative - it helped myself and my family to make the decision and the manager was very helpful and took time to explain every aspect of how the home was planned to work - I was certainly impressed enough by the accommodation and facilities to recommend it to my mother as a suitable place for her to go. In the foyer of the home there was also details of Windle Courts Philosophy of Care and the residents Charters of Rights. The home has an admission process, which gains information to ensure the home will be able to meet the individuals care needs. The Manager confirmed that either her or the unit manager would do the assessment before admission. Three files were inspected and all contained a full assessment. The Manager confirmed that a Contract would be given to all new residents during the admission process and all three files viewed contained a signed and dated Contract. Feedback from the questionnaires was mixed, five stated they had a Contract, but two stated they did not. Intermediate care is not provided at Windle Court. Windle Court DS0000073191.V375265.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service can be confident that they will receive the care they need. EVIDENCE: Three resident’s files were inspected and all contained a care plan, which had been completed around the care needs of the individual residents. Those viewed were of a good standard and provided information to staff on the delivery of care. Care plans had been signed by the resident or their relative to confirm the content and these had been regularly reviewed. Windle Court has a Key Worker system in place and there were communication books in residents bedrooms for notes to be made to assist the Key Workers to communicate with other staff members and relatives. Files viewed had detailed care notes, which included the day-to-day care provided to each Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 11 individual resident. Residents and visitors spoken with were very happy with the care being provided by the management and staff. The three files viewed contained documentation which showed the residents were supported and had access to a variety of healthcare resources (GP, District Nurse, Hospital appointments etc). Appropriate referrals had also been made to other health care professionals when required. Visits from the optician and dentist had also been arranged. Feedback from the questionnaires reported that four residents felt they always received the medical support they needed, whilst four felt they usually did. During a tour of the home it was noted that there was specialist equipment being used to help in the prevention pressure sores. Moving and handling assessments could be found on residents files and these had been fully completed. Appropriate risk assessments were also in place. Regular Regulation 37 forms have been submitted by the Manager to advise the CQC of any falls, deaths or injuries to residents. The Manager stated that they try to ensure Residents are able to stay at the home in familiar surroundings for as long as possible. When viewing the three residents care plans, it was noted there was a space for death and dying wishes to be recorded and all three of these had been completed. There was also a Bereavement Pack in the foyer of the home, which included details of different religions and cultures and services available. There is a policy on the Administration of Medicines, but this was not viewed during this inspection. Medication at the home is mainly managed through a monitored dosage system (Blister packs). As part of the inspection process the administration of the lunch time medication was observed. The medication folder contained photos of the residents to assist staff in identification. Bottles of medication had been dated when opened, records were well maintained, storage was good and no anomalies were noted. It was established that management at the home undertake weekly medication audits to make sure that good practice and systems are maintained. The only area raised was with regard to ensuring residents dignity and respect is maintained when providing medication. The staff member providing medication called across the dining area to one resident to establish whether she required her pain killers. This issue was brought to the Managers attention during the inspection. During the day staff were observed to treat the residents with respect and dignity. Toilet doors were shut, residents were spoken to with respect and there was generally a very good atmosphere within the home. Those who were unable to converse or had ‘special needs’ were included in the day-to-day activities and appropriate care provided. Relatives spoken to were positive regarding the care provided and feedback from the questionnaires included staff have enormous patience and tact - they try hard to do what they can to please and staff are friendly, pleasant and attentive. Windle Court DS0000073191.V375265.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service will be given the opportunity to take part in activities during the day. Users of the service can be assured they will receive food of a satisfactory quality. EVIDENCE: It was confirmed that the home has an activities coordinator and the activities program was on the wall to advise residents of which activities were happening when. Activities that were available included bingo, toiletries trolley, art, gardening, smells and tastes, balloon exercises, hairdressing, nails, one-to-1, board games, music centres, news reviews, books and the television. An advert for a trip to a local butterfly centre was also on the board in the foyer and this was to take place in May/June. It was confirmed that the hairdresser visits the home on Wednesday and one resident added that she looked forward to that. A communion and a short service is often arranged on Sundays at 10:15 a.m. Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 13 Windle Court also has a quiet lounge, which has been turned into a senses room. It had fibre optics, touch and feel boards and also a sea life projector which showed pictures around the wall. On the day of the inspection staff were observed playing with a balloon with residents in one of the lounges and the activities coordinator was also seen handing out pictures to those residents who wished to colour them. Feedback from the questionnaires about the activities at the home were mixed. Four stated that there were always activities arranged for them to take part in, whilst two said usually and one said sometimes. Comments included every effort is made to arrange activities. There is always social interaction which is very important. They make all the residents feel wanted and we do have a laugh and I sometimes get bored, I would like to go out sometimes - it would be nice to have some outings. There is a separate visitors room available if privacy is required. There are also other areas around the home, which are quiet. There is a book in the foyer for visitors to sign when they arrive and leave. Visitors were noted to come and go throughout the day and being made very welcome and offered cups of tea. Those relatives that were spoken to were very complimentary about the home and stated that they were always made to feel very welcome. One relative confirmed that they had often been offered a meal. During the inspection staff were observed offering residents choice in their day to day care and helped to make decisions where needed. One staff member was seen advising a resident who had asked if she could have a shower you can have a shower as many times as you like. Residents were also given the choice on whether they wanted to have their meals in their bedrooms. One observation which was not so positive was with one person coming out of the dining room and stating that they wanted to help to lay the tables. On speaking to a staff member to see if they could help, when they went back into the dining room and advised another staff member that they wanted to assist, the staff made positive comments but then told them to take a seat. It was felt that the staff member did not encourage the resident to assist in laying the tables etc. This issue was brought to the Managers and also the Unit Managers attention. Each dining area had a menu board, which clearly advised the residents what the menu is for breakfast, lunch and tea. There is a four-week menu and there was a good choice of food at all times including the supper. On the day of the inspection, residents had a choice of two hot meals at lunchtime and two choices at tea. During the lunchtime observation the tables have been laid with cutlery, table mats, glasses of juice, salt and pepper and there was silk flowers in vases. Residents who needed assistance and encouragement where provided this by the staff. There were nutritional assessments for each resident. Comments from the residents on the day included cant grumble, food is okay and its lovely. Feed back on the questionnaires showed that six residents always like the meals, whilst two usually did. Comments included Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 14 fantastic meal, no complaints about the food, it is as good as you will get anywhere like this and it is always fresh and very appetising to look at - I enjoy the food. Staff were observed providing residents with hot drinks between meals and there was also orange juice available in the lounges. The lounges also had fruit bowls with a good selection of fruit including apples, grapes, plums, bananas etc. The kitchen was inspected and noted to be clean and tidy. There was an excellent supply of fresh vegetables and fruit and excellent stocks of biscuits and general food products. Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service and relatives can be confident that any concerns or complaints will be listened to and acted upon. They can also be confident that there are systems in place to help them keep safe. EVIDENCE: There is clear written guidance in the Home’s Service Users Guide and Statement of Purpose on how relatives and residents can make complaints. There was also a clear complaints procedure on the wall for relatives and visitors to see. Feedback from the questionnaires confirmed that all knew who to speak to how to make a complaint. On viewing the Complaints Folder some complaints had been received, but these had been fully recorded, investigated and a satisfactory outcome reached. No complaints had been made to the CQC. The Manager stated that she oversees any complaints and that these are also monitored by upper management. The home has policies and procedures for the safeguarding of vulnerable adults and the Manager is aware of the local authority guidelines. The Manager confirmed that staff receive safeguarding training and this is provided via an in-house course. There was evidence that safeguarding training had recently been provided to staff and on viewing the staff training matrix it was apparent that there are only three staff who needed to be trained. During a tour of the Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 16 home it was noted that the staff room had general guidance on Whistleblowing and staff spoken with had a good understanding of safeguarding adults and whistle blowing issues. The home has one safeguarding issue, which is in the process of being investigated. Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that will meets their needs and is comfortable and well maintained. EVIDENCE: Windle Court is a new purpose built home, which provides residents with a spacious and comfortable environment. It is only six months old and the environment and furnishings are set to a high specification. The foyer of Windle Court has been set out with easy chairs and information about the home and there is also a receptionist who is there to help if needed - it is very welcoming. Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 18 There are a number of lounges and dining areas around the home and also small quiet areas to sit in. Residents would be able to have access to all parts of the home and there is a passenger lift to the upper floor. There are hand rails around the corridors to assist residents when walking and doorways to communal areas, bedrooms and bathrooms are wide enough for wheelchair access. Each room has a Call bell system with an assessable alarm and both staff and residents were observed during the inspection using this system. On the day of the site visit the home was generally clean and well presented. A general hand is employed to undertake maintenance tasks and carry out safety checks. There are a number of assessable toilets, which are clearly marked and close to the lounge and dining areas. Bathroom seen were large and had the use of hoists if needed. Each resident also has use of a toilet within their own bedroom. During a general tour of the home it was noted that residents bedrooms were well decorated and personalised. All bedrooms had ensuite facilities and bedrooms doors were clearly marked with the residents name and a picture of their choice. The signage was good around the home to aid orientation. There is very limited garden space. There is a small patio area in the garden, but it was noted that there is no lawn or grassed areas. The garden had raised flower beds which the manager stated she hoped to eventually encourage residents to assist with. The laundry was well set out and has an in and out door to ensure that both clean and dirty laundry are kept separate. There were two washers and two dryers, which laundry assistant stated was sufficient to meet present laundry needs. Each resident had a box for their clean laundry. It was noted that there was lots of hanging space to assist in drying laundry, but the laundry assistant on duty raised that there was lack of space for folding clothes as there was no flat surface within the room. This issue was brought to the Managers attention. Bathrooms, toilets and residents bedrooms had paper towels and liquid soap. The water temperatures were checked in two bedrooms and found to be hand hot and okay. Staff were observed wearing disposable gloves and aprons. Most staff had completed infection control training, but further training needed to be organised for the remaining staff. During a tour of the home it was noted that the sluice door had not been locked and when entering there was a concentrated lemon detergent in the sluice which stated avoid skin and eye contact and wear gloves. This was brought to the Managers attention due to the health and safety of the residents. Bathrooms contained clinical bags the staff to place any clinical rubbish. Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are cared for by qualified, competent and experienced staff. EVIDENCE: Staffing rotas were viewed and these contained details of the staff members name, job title, day, dates and times worked. It was noted there was a signing sheet, which staff signed when they arrived and when their shift started. It was confirmed that present staffing consisted of 3 Care Team Managers and 7 care staff for the morning and afternoon shift. Staffing of the home will increase as the numbers of residents increase. The home also has domestic staff, an office administrator and receptionist to assist in the smooth running of the home. The Manager is supernumery to the staffing numbers and there are also Unit Managers. During the inspection there appeared to be sufficient staff on duty to provide the care required, but when residents were asked whether staff were available when needed, four stated always, whilst four stated usually and one added sometimes there are not enough staff. The files of two recently recruited staff were viewed and showed that correct recruitment practices had been followed. Files contained fully completed application forms, references, Criminal Record checks and proof of identification. It was confirmed that an induction is provided to all new staff Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 20 and this is in line with Skills for Care guidance. Staff files viewed contained details of an induction and all four staff who returned questionnaires confirmed that the induction covered everything they needed to know about the job before they started. The Manager provided a copy of a training matrix, which included details of all staff and dates and when they had completed training and updates where required. This showed that most staff had attended safeguarding, first aid, moving and handling, dementia training, health and safety, food hygiene, fire awareness, cosh and infection control training. There were some areas that staff still needed to be trained in, but courses had been arranged. The whiteboard in the office showed that moving and handling training had been arranged for the 12th of May and safeguarding training had been arranged for the 7th of May. Fire awareness training was to take place on the 14th of May. Those staff spoken to confirmed they had been offered regular training. On discussion with the Manager she advised that four staff had achieved their NVQ two and three staff their NVQ three. Other staff had also registered to do their NVQ training. Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is run and managed efficiently and effectively. EVIDENCE: Windle Court has a new Manager who has been in post for six weeks. The Manager has previous experience in running care homes and has been involved in getting new establishments up and running. Staff, relatives and residents spoken with during the inspection stated that the new Manager was very approachable. There was a notice in the foyer inviting residents and relatives to visit her during Paulines open surgery, to provide them time to raise any concerns or issues they may have. There was a really good atmosphere within the home and staff were observed communicating and laughing with residents Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 22 whilst assisting them in their day to day activities. On the day of the inspection there was a good rapport between the staff at the home and they all appeared to assist each other in the day to day routines. The Manager was observed providing advice to staff and meeting and greeting relatives during the day. There are clear lines of accountability within the home and also external management support if needed. Windle Court has systems in place to monitor the quality of the service it provides. Residents and relatives views are gained through sending out questionnaires and there is also a suggestion box in the foyer for comments. An internal quality report had been completed which was very comprehensive and many of the issues raised in this report had already been actioned by the Manager. Regular monthly visits are completed by upper management to ensure the home is meeting standards. Relative and residents meetings ad also taken place to gain their views on the service provided. In the foyer of the home there was a comment book, which had been completed by visitors. Comment were very complimentary and included excellent care - staff are so very caring and very willing to help. Very please to leave my mother in their care and very impressed with the care my mother has received. Her room is her home and she is treated with respect and allowed her dignity. The Manager confirmed that there are systems in place for those residents who require assistance with their finances, but some do their own or have assistance from families. Four residents monies were checked and these were found to be order. There are also systems in place for regular auditing. The Manager had recently introduced a supervision matrix, which showed when staff had received supervision. These records showed that most staff had received supervision approximately every 3 months. Staff meetings had also taken place and minutes were available. Staff reported that they received regular support. Records were well organised and systems had been put in place to enable the Manager to provide the evidence to show that the National Minimum Standards and Regulations had been met. Regular checks on gas appliances, PAT testing, fire extinguishers, emergency lighting, lift, hoists and fire procedures had taken place. There was also evidence of a general risk assessment of the home. On viewing the document that recorded the water temperature checks, it was established that these had been completed regularly. Documentation of accidents were seen and in order. The homes insurance was displayed on a wall and this was correct and dated 19/8/09. Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 X 3 3 3 3 3 3 3 2 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 3 3 3 3 3 3 3 3 Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 24 New Service 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP9 OP12 OP18 Good Practice Recommendations Ensure staff are aware of the importance of ensuring residents privacy and dignity is upheld when assisting with medication. It is recommended this area is developed further and residents are consulted with on what other activities they may like to take part in. Ensure staff received safeguarding training within 6 months of employment and updates every two years to help safeguard residents within the home and that staff are aware of the correct procedures. Infection Control within the home needs to be continued to be developed. Staff should receive regular training and updates to ensure they are aware of correct procedures. The sluice door should be locked to ensure that residents are kept safe and are not be able to gain access to chemicals. 4. OP26 Windle Court DS0000073191.V375265.R01.S.doc Version 5.2 Page 25 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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