Latest Inspection
This is the latest available inspection report for this service, carried out on 30th June 2008. CSCI found this care home to be providing an Good service.
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.
For extracts, read the latest CQC inspection for Windsor Court.
What the care home does well All the residents spoken with were very complimentary of the care they received and the friendly nature of management and care staff. Residents are only admitted to the home following a full assessment of their needs and having confirmed that the home can meet those needs. Residents are encouraged to maintain their links with friends and family and all visitors are made welcome. Residents like the food provided and enjoy the choices offered at each meal. The complaints procedure can reassure residents that their views are important to the home and that any complaints they raise will be properly investigated. The home protects the residents from abuse by ensuring robust policies and procedures are in place, which staff can easily follow. The house and gardens are maintained to provide residents with a comfortable place to live. Residents are encouraged to personalise their rooms with items of furniture, pictures and a variety of mementos. Sufficient numbers of staff are on duty throughout the day and night to be able to meet the needs of the residents What has improved since the last inspection? Mrs Griffin has been registered with the Commission for Social Care Inspection as manager. The care documentation has improved and staff have sufficient information to be able to meet the needs of residents. The procedures for storage and administration of medication have improved and residents can expect to receive medicines appropriately from competent staff. Recruitment procedures are robust and staff are only appointed when the Registered Manager is satisfied that all the necessary checks have been made. CARE HOMES FOR OLDER PEOPLE
Windsor Court 34 Bodorgan Road Bournemouth Dorset BH2 6NJ Lead Inspector
Amanda Porter Key Unannounced Inspection 30th June 2008 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 Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Windsor Court Address 34 Bodorgan Road Bournemouth Dorset BH2 6NJ 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) 01202 554637 01202 297554 info@win-court.co.uk www.win-court.co.uk Lyndale Healthcare Limited Sharon Griffin [registered 10/7/08] Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58) of places Windsor Court DS0000032192.V364448.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 either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 58. 12th February 2008 Date of last inspection Brief Description of the Service: Windsor Court is located in a quiet tree-lined road in a residential area some three quarters of a mile from Bournemouth town centre with all the facilities that can be expected in a large town, e.g. banks, post office, shops, library and places of worship. Getting to the town centre requires negotiating a steep hill as does accessing public transport, although the nearest bus stop is within 200 yards of the home. Windsor Court was originally a grand gentlemens residence before being converted to a hotel and still retains many of the features and appearance of a building that was used for that purpose, although it is now registered as a care home, providing personal and nursing care for up to 58 older people. The home has a wheelchair accessible entrance area with a small lounge adjacent to the generous hallway. Further communal areas, comprising the spacious dining room, TV and quiet lounges are all located on the ground floor and furnished much as if the premises was still a hotel. All rooms have high ceilings and big windows. There is a secluded garden at the rear of the home that is mainly laid to lawn, surrounded by mature trees and a large car parking area at the front for visitors. Windsor Court is owned by Lyndale Healthcare Ltd, a family business. The Registered Manager is Mrs Sharon Griffin and she is supported in her role by BML Healthcare Ltd. Residents accommodation is located on the lower ground, ground, first and second floors of the home with access between floors via a wide staircase, passenger or stair lifts. Aids and equipment are available for residents who may have disabilities. The home is centrally heated throughout. All of the fifty eight bedrooms are for single occupancy, with fifty-three having their own enWindsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 5 suite WC. The remaining five comprise two pairs of bedrooms, with each pair sharing the en-suite facilities and one room that has an en-suite WC and wash hand basin. Windsor Court provides 24-hour personal care, all meals, laundry and domestic services. Residents are encouraged to participate in a range of activities organised in the home. A monthly inter-denominational religious service takes place in the home. At the time of inspection the weekly fees ranged from £452 - £716. Additional charges include hairdressing, chiropody, dry cleaning, toiletries and newspapers. The Office of Fair Trading has published a report highlighting important issues for many older people when choosing a care home, e.g., contracts and information about fees and services. The CSCI has responded to this report and further information can be obtained from the following website: http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_ choosing a care home .aspx A copy of the home’s inspection report will be made available to anyone wishing to read it upon request to the manager. Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes.
Two inspectors carried out the unannounced key inspection over approximately five hours on the 30th June 2008. This was a statutory inspection and was carried out to ensure that the residents who are living at Windsor Court are safe and properly cared for. Requirements and recommendations made as a result of the last inspection visit were also reviewed. The Registered Manager, Mrs Sharon Griffin, was on hand throughout to aid the inspection process. Information gathered for this report came from several sources including: • Reports made to the Commission for Social Care Inspection by the home. • The annual quality assurance assessment completed by the home. • 7 questionnaires completed by residents, 4 by relatives and visitors, 2 from visiting GPs, 1 from a health professional and 4 from staff. • Tour of the premises. • Review of a variety of documentation including care records, staff records, maintenance records, policies and procedures. • Discussion with residents and staff. During the course of the inspection five residents and six members of staff were spoken with and asked their views on the service provided at the home. Comments received through the questionnaires and discussion included: “Lovely friendly home to both residents and visitors.” “It offers a friendly caring environment, there is a family atmosphere.” “Very helpful office staff and the remainder of the staff are very friendly and helpful.” “We have a very professional manager, who gives us all of the information required to do our job in the correct manner. We have her full support in what we do, to make a good service to our residents here at the care home.” What the service does well:
Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 7 All the residents spoken with were very complimentary of the care they received and the friendly nature of management and care staff. Residents are only admitted to the home following a full assessment of their needs and having confirmed that the home can meet those needs. Residents are encouraged to maintain their links with friends and family and all visitors are made welcome. Residents like the food provided and enjoy the choices offered at each meal. The complaints procedure can reassure residents that their views are important to the home and that any complaints they raise will be properly investigated. The home protects the residents from abuse by ensuring robust policies and procedures are in place, which staff can easily follow. The house and gardens are maintained to provide residents with a comfortable place to live. Residents are encouraged to personalise their rooms with items of furniture, pictures and a variety of mementos. Sufficient numbers of staff are on duty throughout the day and night to be able to meet the needs of the residents What has improved since the last inspection?
Mrs Griffin has been registered with the Commission for Social Care Inspection as manager. The care documentation has improved and staff have sufficient information to be able to meet the needs of residents. The procedures for storage and administration of medication have improved and residents can expect to receive medicines appropriately from competent staff. Recruitment procedures are robust and staff are only appointed when the Registered Manager is satisfied that all the necessary checks have been made. Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 9 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 Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard is not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admissions procedure enables prospective residents, and/or those acting on their behalf, to make informed decisions about admission to the home and ensures that only residents whose needs can be met by the home are offered places there. EVIDENCE: The care files for new residents were inspected. These showed that the home has a good procedure in place. Prior to anyone moving into the home a full assessment of needs was undertaken with the prospective resident. Sufficient information was obtained so that a care plan could be drawn up and made available to staff.
Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 11 Residents spoken with confirmed that they or a family member had visited to the home and were given sufficient information about the home before making a decision as to whether to stay. Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to provide staff with the information they need to meet the health and personal care needs of residents. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Since the last inspection the standard of written assessment and care planning had greatly improved. The care documentation for four residents was reviewed and it contained the relevant assessments and care plans needed so that staff had the information to be able to give a good standard of care. The care plans were evaluated on a monthly basis. However there were still some shortfalls in recording that were noted. One care file did not contain a care plan relating to wound care. Generally the daily written statements in the care files lacked
Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 13 detail about what sort of day the resident has had, how they have been occupied and whether they were in a state of well or ill being. Where the need for specialist equipment was identified it was provided. It was clear from discussions with staff and residents that they have access to the health services they need. There was evidence to show that residents get support from General Practitioners, district nursing services and chiropodists. The home has a good medicines policy and procedure in place. Examination of records indicated that medicines are properly administered in accordance with the prescriber’s instructions. Residents and the visitor spoken with were happy with the care they or their relative received and confirmed that staff treated them with respect and were supportive and kind. Comments received included: “Staff are very courteous and respectful.” “Staff are very good.” Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides some individual and group activities and opportunities, which includes links with relatives and family members and respect for individual preferences promoting a good quality of life for residents. EVIDENCE: Residents spoken with said they were happy with the lifestyle that living at the home afforded them. Some chose to spend time on their own but knew they could join in with any organised activities if they so wished. Activities included: • Gentle exercise class • Bingo • Flower arranging • Skittles • Arts and crafts • Puzzles
Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 15 • • • Musical entertainment Nintendo Wii Outings. Residents are able to attend church services if they wish. Visiting clergy are made welcome. There was evidence from residents and visitors that visitors are made welcome at any time and that they are able to spend time privately in residents rooms if wished. Rooms viewed were personalised with pictures, some ornaments and items of furniture. People said they enjoyed the food provided. Records showed that residents’ likes and dislikes with regard to food were known and residents were aware that alternatives to the main menu were always available. Residents said: “The food is very good.” “I like the choice of food.” Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure. Protection from abuse is promoted. EVIDENCE: Residents and their representatives have access to the complaints procedure. Residents said that they knew how to complain and felt confident that if they had concerns or complaints they will be listened to and taken seriously. The complaints log showed that the manager had received five complaints all of which had been investigated and resolved appropriately. The home has developed and implemented written policies and procedures for the protection of residents from abuse or neglect and provides all staff with training in the understanding of abuse and their role in protecting residents from abuse in its many forms, including neglect. Care staff spoken with during the inspection confirmed that they had received such training. Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 17 Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment at Windsor Court is very good providing residents with an attractive, homely and safe place to live. EVIDENCE: A tour of the premises and review of maintenance documentation showed the home is well maintained inside and out. There was evidence that equipment is serviced regularly. The home has an ongoing programme of maintenance and refurbishment. Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 19 Residents have easy access to all communal areas. The well-tended garden is attractive and easily accessible. Resident’s rooms were furnished appropriately. Bedrooms were personalised with a variety of mementos, pictures and small items of furniture. All areas of the home seen during the inspection were clean, bright and free from any unpleasant odours. Surveys completed indicated that the home was always kept clean. The laundry was well managed. Adequate supplies of clean linen were seen to be available. Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient care staff are employed to meet the needs of residents. Robust recruitment procedures are in place to protect residents from the risk of unsuitable staff working at the home. New staff are not given always given sufficient training and support so that they can meet the needs of residents living at Windsor Court. EVIDENCE: At the time of inspection staff rosters demonstrated that there are sufficient staff on duty at that time. However the home is still reliant on employing agency staff, on a temporary basis, so that staffing levels are kept up. This may mean that the continuity of care to residents is disrupted. Mrs Griffin is keen to recruit a full compliment of staff as soon as possible. During the inspection staff were on hand to meet the needs of the residents. Residents spoken with confirmed that staff were on hand when they needed them and they were not kept waiting. Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 21 The home has an ongoing training programme, which includes NVQ level 2 and 3 in care; however, under 50 of the care staff hold the minimum of a level 2 award in care. Five staff recruitment files were reviewed. The files were well ordered and contained all the information required by law. POVA first and enhanced Criminal Record Bureau checks had been obtained for all new staff. However written confirmation of POVA first checks need to be held. Training files demonstrated that staff were receiving some induction training. However the induction programme used was not in line with the Skills for Care guidelines. It was also noted that the induction had been completed within two weeks, which may be insufficient time for the staff member to be competent especially if they had no previous experience in care. Staff confirmed that they were encouraged to take up training opportunities provided. Recent training including: • Fire safety • Moving and handling • Protection of vulnerable adults • Health and safety • Managing challenging behaviour. Through discussion it was evident that staff were not sufficiently trained in first aid, which meant that people in the home may be put at risk should an untoward incident/accident or health problem occur. A requirement has been made that staff are trained in first aid under Standard 38 of this report. Further information on available training can be accessed through the following websites: www.picbdp.co.uk www.skillsforcare.org.uk Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is very well organised and the daily management and running of the home centres completely round the care of residents. Very good management practice, systems in place, and records kept, confirm the health and safety of all in the home. EVIDENCE: Since the last inspection Mrs Griffin has been registered with the Commission for Social Care Inspection as manager. Through discussion it was evident that
Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 23 residents and staff enjoy the way the home is run and find the Registered Manager is very approachable. Mrs Griffin demonstrated throughout the inspection that she runs the home well. There has been a large turnover of staff in the last twelve months and Mrs Griffin is working hard to recruit appropriate staff and build up a team of staff who will be able to give a good standard of care to residents. As previously mentioned there are still some staff vacancies and the home employs agency staff to fill them on a temporary basis. This means that there may be some lack of continuity of care that is given to residents. There is a quality assurance and quality monitoring system in place. The home takes steps to review its performance regularly and residents’ views are sought and suggestions put forward are acted upon. The Registered Manager and residents spoken with confirmed that residents either deal with their own finances or have a representative to do so. The home will hold a small amount of money for residents if they so wish. Records showed that staff had received recent training in fire safety and manual handling updates. Substances hazardous to health were seen to be stored securely. Records showed that equipment had been serviced regularly. Accidents were recorded and appropriate action was taken as necessary. Training records showed that staff were not sufficiently trained in first aid. Mrs Griffin confirmed that training will be provided in the future. Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 24 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 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO 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 OP30 Regulation 18(1) Requirement The registered person must ensure that new care staff receive induction in line with the Skills for Care guidance. The registered person must ensure that a qualified first aider is on duty at all times. Timescale for action 30/10/08 2. OP38 13(4) 30/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP28 Good Practice Recommendations Daily records should reflect the wellbeing of the resident. It is recommended that a minimum of 50 of care staff achieve NVQ level 2 training. Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 26 3. OP38 The registered person should provide first aid training for staff. Windsor Court DS0000032192.V364448.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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