Care Home: Windsor Nursing Home

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What the care home does well Information about people’s past lifestyles and choices are written down so that staff can continue to support them or help them access help from others. The administration of medicines is generally well managed and the personal wishes of service users are considered when agreeing when and where to administer medication. Visitors are always welcomed and there are links with the local community. Staff are respectful and sensitive with people when helping them or when speaking to them. The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced diet. Clear information is available should anyone have a concern or complaint about the care or service they are receiving. The registered manager makes sure that all checks and clearances are received before staff are employed. Staff receive on going training so that they can care for the different needs of people living in the home. They have completed safeguarding training and feel confident that they can recognise signs of abuse would be able to raise an ‘alert’ and protect those at risk. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. The Registered Manager makes sure that quality assurance systems are followed so that people receive consistent quality of care and their views are taken into account. People living in the home said: “They are precious girls.” “Good girls.” “Lovely staff.” “She is a good cook.” “Lovely food.” “I am looked after and I am happy here.” “They care for all my mam’s needs.” Relatives said: “The staff are nice; they and the manager are easily approachable.” “We are happy with the care provided nothing is a trouble.” “Any concern is addressed straight away.” Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 What has improved since the last inspection? The home has had a major variation to registration and can now provide care for eleven people with dementia care needs. The assessments are more detailed and cover aspects of care including preferences, and cultural needs. Care plans continue to improve and are becoming more person centred. Foot-operated bins have been provided in bathrooms, toilets and sluices. Clean lined is now stored properly. The manager has become registered with the Commission. In house maintenance continues to improve the inside and outside of the home. The window restrictors and shower hoses are now fitted properly. What the care home could do better: The Service User Guide and other information could be put in easier to understand styles. Staff must record all medicines that are ordered for people living in the home. Appropriate beds need to be supplied when people’s health care needs change. Further work on the Dementia Care Unit should continue to help people with memory loss find their own way around the units and keep them stimulated and interested. The planned maintenance needs to continue so that the home remains a safe pleasant place to live. Key inspection report CARE HOMES FOR OLDER PEOPLE Windsor Nursing Home Victoria Road East Hebburn Tyne And Wear NE31 1YQ Lead Inspector Irene Bowater Key Unannounced Inspection 26th May 2009 09:00 DS0000000279.V375437.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. Windsor Nursing Home DS0000000279.V375437.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 Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Windsor Nursing Home Address Victoria Road East Hebburn Tyne And Wear NE31 1YQ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0191 4301100 0191 4301100 Dr Inder Paul Vinayak Dr Veena Vinayak Andrea Rowe Care Home 38 Category(ies) of Dementia (11), Old age, not falling within any registration, with number other category (27) of places Windsor Nursing Home DS0000000279.V375437.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 within any other category - Code OP, maximum number of places: 27 2. Dementia - Code DE, maximum number of places, 11 The maximum number of service users who can be accommodated is 38 19th June 2008 Date of last inspection Brief Description of the Service: Windsor Nursing Home provides nursing care for people from the age of 55 years and over, and personal care, for up to 38 people. There has been a change in registration and the home can offer 11 places for people with dementia. The home is purpose built and has two floors, access between floors being with a passenger lift as well as stairs at either end of the building. There is easy access to the home and garden, corridors and doorways are wide to accommodate wheelchairs. There is a lounge and dining room on each floor with a conservatory adjoining the rear of the ground floor lounge. All of the bedrooms are for single occupancy and have en-suite toilet facilities. The home is situated between the towns of Jarrow and Hebburn and is within easy access to the local town centres, public transport, local parks and many other amenities. Fee rates for people needing general nursing care are: £531.73 Fee rates for people needing dementia nursing care are: £541.73 Fee rates for people receiving continuing care are: £570.73 The free nursing care element is included and that is set nationally. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 5 Fee rates for people needing personal care are: £437.93 Not included in the cost are personal items such as toiletries, newspapers and hair dressing. Any outing also has an individual cost. Windsor Nursing Home DS0000000279.V375437.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 that the people who use this service experience good quality outcomes Before the visit: We looked at: • Information we have received since the last visit on the 19 June 2008. • How the service dealt with any complaints and concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service and their relatives, staff and other professionals. • We have reviewed our practice when making requirements, to improve national consistency. • Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. • In future, if a requirement is repeated, it is likely that enforcement action will be taken. The Visit: An unannounced visit was made on the 26 May 2009.This visit was carried out by one inspector and started at 09:30 and was completed at 16:30. During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors. • Looked at information about the people who use the service and how well their needs are met. • Looked at other records, which must be kept. • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for. • Looked around the building to make sure it was clean, safe and comfortable. • Checked what improvements had been made since the last visit. • We told the Registered Manager what we found. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 7 What the service does well: Information about people’s past lifestyles and choices are written down so that staff can continue to support them or help them access help from others. The administration of medicines is generally well managed and the personal wishes of service users are considered when agreeing when and where to administer medication. Visitors are always welcomed and there are links with the local community. Staff are respectful and sensitive with people when helping them or when speaking to them. The menus offer a variety of well-cooked nutritious meals. People can enjoy a healthy, well-balanced diet. Clear information is available should anyone have a concern or complaint about the care or service they are receiving. The registered manager makes sure that all checks and clearances are received before staff are employed. Staff receive on going training so that they can care for the different needs of people living in the home. They have completed safeguarding training and feel confident that they can recognise signs of abuse would be able to raise an ‘alert’ and protect those at risk. There are good arrangements for supporting people to keep their personal monies in a safe place if they want. The Registered Manager makes sure that quality assurance systems are followed so that people receive consistent quality of care and their views are taken into account. People living in the home said: “They are precious girls.” “Good girls.” “Lovely staff.” “She is a good cook.” “Lovely food.” “I am looked after and I am happy here.” “They care for all my mam’s needs.” Relatives said: “The staff are nice; they and the manager are easily approachable.” “We are happy with the care provided nothing is a trouble.” “Any concern is addressed straight away.” Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 8 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. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 9 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. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 11 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): 1, 2, 3. Standard 6 is not applicable to this service. 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 receive clear information about the service and good assessments of need before admission. This helps them make the right decision about using the service. EVIDENCE: The home has a Statement of Purpose and Service User Guide, which is readily available in the main entrance to the home. These have been brought up to date to show the staffing and change in registration. These are not yet in large print, audio or picture style. Each person has a contract which show what is included in the fee and the role and responsibilities of the provider and the rights of the person. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 12 Everyone admitted to the home has an assessment of all their care needs, which is completed by care managers, nurse assessors and the home manager. The assessments provide information about peoples care, previous history and social activities. The assessments have been changed so that more detail about preferences and cultural needs are included. This information is then used to complete a plan of care for the individual living in the home. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 13 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): 7,8,9,10. 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. Care is being planned and delivered in a respectful and person centred way. This enables people to fully access healthcare and other services and ensures their needs are supported. EVIDENCE: Each person has a plan of care based on the admission information, which was carried out by care managers, the home manager and where necessary nurse assessors. Staff have completed pressure ulcer risk assessments, using the Waterlow tool, dependency, moving and assisting, nutritional assessments using the Malnutrition Universal Screening Tool (MUST), continence and fall risk assessments. These tools help the staff understand the level of risk to people’s Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 14 physical and health care needs and then forms the basis of the care plan to guide staff about how to prevent or manage the person’s care in those areas. The staff have continued to improve the care plans since the last visit to the home. There is evidence that staff are working with the person and their relatives to find out about their previous lifestyles and histories. This information is then used to show how show how they are promoting people’s independence and choices about daily living. Care plans showed in detail how people’s physical care needs were met. For example one person will only eat small amounts from a tea spoon, weights are to be checked and advice from the Dietician and Speech and Language Therapist are followed. Another person “struggles with full meals” and finger foods and supplements are provided to make sure that nutritional needs are met. Food likes and dislikes are recorded and food and fluid charts are in place for people who have poor appetites or have lost some weight. The moving and assisting information is available but further information is needed to show which hoist, sling and number of staff are needed to support the person. One person is being nursed on a mattress on the floor as there is a great risk of falls. Advice from specialists needs to be sought so that the home can provide an appropriate bed which will ensure safety for the person and staff especially regarding moving and assisting. There are nursing profiling beds and equipment is in use to maintain people’s skin integrity. They also contained detailed information about the person’s lifestyle before they moved in, their likes and dislikes, and aspects relating to their social care needs. For example, “likes knitting”, “likes singing” “used to play the piano” and is an avid football supporter. Everyone has access to all NHS facilities to ensure their healthcare needs are met. There are regular visits from GP’s and other health professionals including, dentists, opticians and chiropody services. Advice is also sought from speech and language therapists, dieticians, occupation therapists, psychiatrists and continence advisors. This ensures that the right advice and guidance is provided by specialists to help the staff meet people’s diverse range of needs. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 15 All of the staff had a good understanding of individual needs and were alert to changes in people’s mood and made sure that support and assistance was given in a discreet sensitive manner. The home has policies and procedures to make sure staff administer all medicines safely. Records are in place for all medicines received, administered and disposed of. However since changing pharmacist there has been a lapse in recording medication ordered by the home staff. Should there be any discrepancy it would not then be possible to carry out a detailed audit. There is a register of staff who are authorised to administer medication. Currently this is only completed by qualified nurses. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 16 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): 12,13,14,15. 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. Opportunities to take part in meaningful activities and keep control of everyday decisions are good and mealtimes are well organised. This means people can lead full and active lives. EVIDENCE: The home benefits from an enthusiastic activities person who organised events both inside and out of the home. Events are displayed and include, bingo, dominoes, and arts and crafts, pamper days, sing a longs and quizzes. There have been outings to see the Wizard of Oz and there are outings to the local park to watch bowls. Some people prefer to stay in their rooms and the staff team respects this. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 17 Recently one person has celebrated a 106 birthday and there was evidence of everyone enjoying the event and the person visiting a favourite football club. Since the last visit to the home there has been a variation to registration and the home has a small dementia care unit upstairs. Some work has been done to make sure people with memory loss can find their way around the unit. For example, there are different coloured bedroom doors with people’s names on and directions given to bathrooms and toilets. A small “sensory” room has been created with various equipment such as Fibre optic lighting and music. This is a quiet area where people can go with a carer to relax People can also access some memorabilia and the lounge has large posters of past film stars and pub them area. Discussion tool place with the manager of how this unit could be further developed using best practice guidance. This would help people with memory loss maintain a degree of independence and provide a more stimulating day for them. The home has adopted a cat and there is a fish tank which provides an interesting interlude for some people. Lay preachers from the Roman Catholic Church visit the home on a regular basis and visit anyone who wishes to see them. Should anyone have any other faith or denomination the home would make provision so that this could be met. Many people have brought small items with them making their rooms homely and reflective of their lives before they moved in. There are dining rooms on each floor. The tables were set with cloths, cutlery crockery and condiments. The upstairs dining room was not as well presented as downstairs and the use of plastic aprons to protect people’s clothing should be looked at as well as the use of plastic drinking glasses. There is a small kitchenette upstairs and the fridge contained jam’s yoghurts, some sandwich fillings, milk and juices so that staff can prepare snacks at any time. People are asked for their preference for each meal and they are also able to change their mind at the point of service. Some preferred to have their meal in their own room and this service was provided by the staff. Although menus are displayed on a chalk board outside the dining room they are not available in large print or picture style which would assist people with poor eyesight and or memory loss choose their meal better. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 18 The lunch time choices were steak pie or liver and onions with potatoes, cabbage and carrots followed by peach crumble and custard and or ice cream. Plenty of soft drinks were available through out the meal. The meal was nicely cooked, good portion size and well presented. The meal time experience on all units was an unhurried and social time and staff were aware of people’s needs and gave support in a sensitive way. Comments about the meal included: “She’s a good cook” “Enjoyed my dinner” “Always lovely food” “Had enough dinner, prefer my pudding”. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 19 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): 16,18 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. Good complaints and protection procedures are in place to ensure that people and their relatives are listened to and protected from harm. EVIDENCE: The home has a complaints policy and procedure, which is easy to understand. It is in the Service User Guide and displayed in the reception area of the home. The complaints book records all concerns with action and outcomes to prevent complaints from recurring. Relatives spoken with said they knew how to make a complaint and said that any concern was dealt with straight away. Staff are trained in Safeguarding Adults procedures so can recognise abusive situations and would know what to do if they suspected abuse. There is also written information and guidance available in the home for staff to look at it if they need further guidance. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 20 There have been three complaints since the last visit and the home raised one safeguarding alert both to the Commission and Local Authority. All have been resolved to everyone’s satisfaction. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 21 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): 19,20,21,24,26. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The ongoing investment is providing a more comfortable, pleasant place for people to live. EVIDENCE: The home has communal areas, bedrooms, bathrooms and toilets on each floor. There is a level entrance and access to the secure garden is by the side door in the downstairs lounge. Since the last visit to the home a major variation has been approved and there is a separate eleven bedded dementia care unit upstairs. This provides Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 22 bedrooms, lounge, and a sensory room with the dining room being a shared facility. Some work has been done to provide an environment that provides interest and stimulation for people with memory loss but more work is needed in this area. For example themes, items of interest such as pictures that people can touch and feel. The downstairs lounge and dining room are nicely decorated and furnished, however the carpet in the upstairs dining room is stained and needs to be replaced. And despite redecoration of corridors there is some damage to walls and doors from trolleys and wheelchairs. Many of the extractors in bathrooms and toilets were not working and there is some damage to the flooring in a bathroom where the bath has been replaced. All bedrooms have an en-suite toilet and washbasin. Bedrooms have been redecorated and people have been encouraged to bring small items with them, making their own rooms highly personalised and reflective of their lifestyles. Some profiling nursing beds have been provided but one person who is at risk of falls is being nursed a mattress on the floor. This compromises her dignity and is a possible health and safety risk. A suitable bed needs to be provided for her comfort and safety. The laundry is small but organised. The walls are ready for redecoration and there is some damage to the door lintel. On the day of the visit the home was clean, tidy and fresh smelling. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 23 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): 27,28,29,30 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. Staffing levels and systems around recruitment, selection and training of staff are good and meet the range of needs of the people using the service and protect them from harm. EVIDENCE: There are thirty three people currently living in the home and people have varying social and health care needs. On the day of the visit there were two qualified nurses, two senior carers, five carers, three domestic, a cook, kitchen assistant, administrator, activities, and maintenance staff on duty. Care staffing levels are reduced to five in total in the afternoon. The records for recruitment were satisfactory. There was evidence of Criminal Record Bureau checks, Safeguarding Adult checks, two written references, proof of identity and professional identity numbers for registered nurses to ensure that suitable people are employed. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 24 New staff have an induction period, which sets out standards about all areas of care and employment. Care staff have either National Vocational Qualifications (NVQ) level 2 or 3 and more staff are planning to complete NVQ level 3. Training files show mandatory training up to date. Also staff have completed resuscitation, anaphalylaxis, palliative care and dementia care training. Further training in infection control, deprivation of liberty and safeguarding is planned. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 25 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): 31,33,35,36,38. 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. The home is run by a competent manager who makes sure that quality assurance and safety systems are in place. This makes sure that people receive a good quality of care. EVIDENCE: The manager has been in post for a year and is now registered with the Commission. She is a first level nurse with many years of experience in care of older people. In addition, she has had experience as a deputy manager for five Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 26 years and has completed a Diploma in Dementia Care. She is completing the Registered Managers Award. Quality assurance systems are in place and regular meetings are held. The manager says there is “an open door policy.” And relatives and people living in the home said the manager was approachable and would discuss any issue with them. The AQQA was completed and returned when asked for and the information gave a reasonable picture of how the home plans to develop over the next year. Records of personal money kept on behalf of individuals were looked at. Information is held in a bound, hard backed book. Clear information is available about all expenditure which can bee cross referenced to receipts. A check of three people’s money found no discrepancies. All internal maintenance records and external certificates are up to date. Accidents are recorded and there is a monthly analysis to monitor and track trends. Risk assessments for safe practices including use of bedrails are in place and up to date. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 27 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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 2 X X 2 X 3 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 X 3 X 3 3 X 3 Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 28 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 OP9 Regulation 12,13 Requirement The registered persons must make sure that there is a record of all medicines ordered by the staff in the home. This will make sure staff can be sure people receive the correct medicines and any errors easier to identify. The registered persons must ensure the dining room carpet is replaced as part of the planned maintenance plan. This will ensure that room remains a safe and pleasant place to have meals. The registered persons must ensure that the flooring in bathrooms is replaced as part of the planned maintenance plan. This will make sure the people live in a safe and comfortable environment. The registered persons must ensure that all extractor fans in bathrooms and toilets are in working order. DS0000000279.V375437.R01.S.doc Timescale for action 12/06/09 2 OP20 16,23 01/12/09 3 OP21 23 01/12/09 4 OP21 23 30/06/09 Windsor Nursing Home Version 5.2 Page 29 5 OP24 16,23 This will make sure that people live in a safe and comfortable environment. The registered persons must 30/06/09 ensure that suitable nursing beds are provided. This will make sure people have the appropriate equipment so that their assessed needs can be met and their dignity and safety is not compromised. 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 4 5 6 Refer to Standard OP1 OP8 OP15 OP15 OP20 OP26 Good Practice Recommendations It is recommended that the Service User Guide is available in other formats so that is easy to understand. It is recommended that serial numbers of hoists and slings are recorded in the risk assessments and care plans. It is recommended that the practice of using plastic aprons for people at meal times is reviewed. It is recommended that the menus are in large print and picture style so that they are easy to understand and are available on dining tables. It is recommended that further development of the dementia care unit progresses in line with best practice guidance. It is recommended that the walls in the laundry be cleaned on a planned basis. Windsor Nursing Home DS0000000279.V375437.R01.S.doc Version 5.2 Page 30 Care Quality Commission St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. 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