Inspection on 01/08/08 for Waterloo House

This inspection was carried out on 1st August 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Waterloo House 22/06/07

Waterloo House 12/06/06

Waterloo House 29/11/05

Waterloo House 29/09/05

Waterloo House 23/11/04

Waterloo House 23/06/04

Similar services:

22 Sandown Road

The Highlands

Turret Villa Retirement Home

Dilston College Of Further Education

West View House

Moor House

Prince Bishop Court

Park View (15)

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Waterloo House Waterloo Road Blyth Northumberland NE24 1BY Lead Inspector Carole McKay Key Unannounced Inspection 1st August 2008 09:15 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 Waterloo House DS0000000639.V369526.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. Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waterloo House Address Waterloo Road Blyth Northumberland NE24 1BY 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) 01670 351992 01670 356328 no email Mr Sewa Singh Gill Mrs Brenda Nicholson Care Home 46 Category(ies) of Dementia - over 65 years of age (12), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (33) Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 2007 Brief Description of the Service: Waterloo House is a two storey adapted building. The home does not have gardens, though there re raised flower beds and mature trees at the entrance to the car park. A small sitting out area is located near the front entrance to the home. Parking for a small number of cars is available at the front of the home within a general amenity area. The home is well located, in walking distance of the centre of Blyth. Bedrooms and communal areas are distributed across both floors and the office/reception area is immediately inside the main entrance hallway. The home has a large established staff team of ancillary, care, and senior care staff plus one manager. Waterloo House is registered to care for older people and people with dementia who are also over 65. Fees for the home range from £429.56 to £435.13 Hairdressing, newspapers, taxis and private chiropody are charged for separately. Waterloo House DS0000000639.V369526.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 1 star. This means the people who use this service experience adequate quality outcomes. In line with current CSCI policy on ‘Proportionality’ the inspection focused upon a number of key standard outcomes for service users. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last key inspection visit on 22 June 2007 • Information from the random inspection on 29 February 2008. • How the service dealt with any complaints & 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. • Sent out surveys to staff and service users to complete. None of these had been returned at the time of this report being completed. The Visit: An unannounced visit was made on 1 August 2008. During the visit we: • • • • • • • Talked with people who use the service, staff and the manager. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. Left surveys for relatives and visitors to complete. None of these were returned in time to be included in this report. We told the manager/provider what we found. Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Adopt a more efficient record keeping system that so that more management time can be spent on care rather than administration. Review the way the home is maintained so that essential work is carried out before emergencies happen. This will ensure the comfort and dignity of the people who use the service. Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 7 Plan internal and external improvements to the home in consultation with service users and other parties. This will improve the general quality of the premises and promote the dignity of the people who live at Waterloo House. Make sure that the procedures for accounting for service users’ medication and monies are clear and followed by all staff, this will protect the interests of service users. Make sure that the improvements that have begun to do with staff supervision, staff training and infection control are followed through so that service users receive care that follows best practice. 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. Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 8 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 Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 9 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who come to live at the home will have their needs assessed so that they will be assured these can be met. The home does not provide intermediate care. EVIDENCE: The home has made several new admissions in the last year. The service user plan for a person more recently admitted was examined during the visit. This showed that the home had obtained an assessment from the person’s care manager prior to admission. This included a specialist risk assessment. The person had needs that fall outside of the categories of care that the home is registered to provide for. But the home had carried out an in house assessment of this person’s needs and the manager said that she was satisfied that the home could offer the care this person required for the short- term stay. Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 10 The same service user said that they were happy with the care received, describing it as ‘ second to none’. The assessment process is comprehensive and includes risk assessments and management plans for identified risk. These are linked to the assessment provided by the care manager. Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 11 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. People who live at the service will have their health care needs safely met in ways that they prefer. EVIDENCE: At the last inspection the manager was required to identify in service user plans where people lacked capacity to give consent. The assessment has been revised but the service user plans do not reflect this as yet. The manager said that all of the plans had been reviewed recently and that she was working with service users’ care managers to complete this. The service user plans for five of the people living at the home were examined. Two of these were examined in detail. These showed that the each person has an up to date plan. Most had been evaluated in the past month. Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 12 Each plan included specific risk assessments for general dependency, falls, nutrition, pressure sores and moving and transferring. Some of these were not dated and signed. Other risks were highlighted in the more general risk assessment, such as confusion and wandering. A new falls risk assessment tool has been introduced since recent training. And the home has received an accredited award for staff training in this area. A process of monitoring and analysing falls has been introduced very recently. Management plans were in place to address the risks. Specific plans were in place for supporting people with personal care, where this was an identified need. These were detailed and described the action staff needed to take as well as the things the person could, or preferred to do themselves. The plans have a section for recording care provided by other health professionals. These show a good level of involvement for GPs, and district nurses. The manager and care staff referred to agreements reached with family representatives to do with restrictions in the best interests of a service user. But this was not as fully documented as it could be. There was evidence that one person was poorly and needed to have their food and fluid intake monitored. Charts for this purpose were in place in the person’s room, so that staff could complete at each visit to the person. The GP had been requested to attend that same day. Medication arrangements were also examined. Storage of medication is adequate but small. It is secure and there are procedures for the access to keys. The stocks of medication are well controlled. The home has two medication trolleys, one for each floor. Both are secured in a locked cupboard when not in use. The controlled drugs cupboard is wall mounted metal and inside the main cupboard. The register and stock were cross-checked and correct. The medication trolleys are tidy and well managed. The medication administration records (MAR) folders have been recently renewed and the photographs have been updated. One handwritten entry was found in the record. This entry was not dated and countersigned. The home has updated its medication procedure following recent training. The new procedure was examined. This is silent on handwriting into the MAR. Medication training has been provided to all staff that administer medications in the past six months. The documents from this how that it is comprehensive training. Staff said that their competence to administer using the home procedures is assessed by the senior staff in the home before they are allowed to do so, but this is not formally recorded. Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 13 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. People living at the service will have their lifestyle choices and interests upheld as far as is possible and in their best interest. EVIDENCE: The service users’ plans show that the home assesses the social needs of service users, taking into account their religious beliefs, hobbies, pastimes and interests. One of the people living at the service said that she is regularly taken out to the shops and to the local church. St John’s provides a library service to the home. Some of the people who live at the home were reading newspapers and magazines during the inspection. Music was playing in the main lounge. A steady stream of visitors occurred during the inspection. The manager and senior staff took phone calls from relatives. Other people are supported to attend day centres regularly. In the home there has been some investment made in equipment and materials for craft and Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 14 exercise. A room has been designated as an activity room. The home does not have an activity coordinator, but the manager said that she would like this to happen. The manager has used surveys to find out what people feel about the home and a comments/suggestion box is also used. There have been some comments made about a decision by the provider to remove a drinking water cooler from the dining room, asking that this be returned. And bigger chairs and more games were mentioned. The notes also contained a thank you to the staff for a recent trip to the local mining heritage museum. Blyth once had one of the largest coalmines in Northumberland. A large picture of the coal staithes at Port Blyth is hung in the dining room. The home used to have a relative and resident committee. The manager said that she plans to reinstate this and to continue building links with the local community. The menus for the home are extensive. They provide a choice of two meals at each main mealtime and two cooked meals per day. They menus rotate every six weeks. The cook has a file that includes the individual preferences and special needs for each of the people living at the home. And a folder of photographs of main meals has been put together, as an aid to people making informed choices. This is also in the kitchen. People said that the food was good. The food for lunch was sampled. It was hot, tasty and colourful. The cook said that she has to prepare a soft diet for one person and that she took account of good presentation when making this meal. One of the staff was taking a trolley around the home so that people could take morning drinks in their bedrooms if they preferred. The cups were all very different in design, shape and condition. Brenda said that this is because a lot of the people who live at the home like to have their own cup. Waterloo House DS0000000639.V369526.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. 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. The manager welcomes comments from the people who live at the home and their representatives. Concerns are responded to and the service has improved the way it protects its service users. EVIDENCE: The home has a complaints policy and procedure. A copy of this is posted in the hallway and is available in the welcome pack. The suggestion box is nearby and is used. Recent comments about the loss of the water cooler have been recorded in the complaints record and faxed across to the provider for consideration. The Commission for Social Care Inspection (CSCI) has not received any complaints. One matter of safeguarding has been raised by the home and one by a visiting professional, since the last key inspection. A random inspection has been undertaken and requirements and recommendations were made for improvement in this area. Since then all staff have received training in this area and the home’s procedures have been revised in consultation with the local safeguarding team. Brenda said that she is waiting for comments in writing from the team before Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 16 issuing the new procedures to the staff team. Brenda is also waiting for copies of the local procedures for safeguarding people from abuse. Staff have also had some in house training regarding the law and people being able to make decisions, as well as guidelines to do with managing behaviour. Waterloo House DS0000000639.V369526.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live at the service personalise their space and will experience some improvement in their environment. A slow response to make major repairs detracts from the comfort and convenience of service users in some areas. EVIDENCE: In the past year improvements have been made to some parts of the home. Externally the bin stores have been screened from view. This makes for a slightly better impression at the main entrance. The flowerbeds at the front of the home are still largely untended. Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 18 Internally, new beds and bedding have been purchased. Several rooms have been redecorated, including bedrooms, bathrooms and toilets. New carpets have been laid in some rooms. But bathrooms are bare and rather institutional. The home was odour free and clean. The dining room wallpaper is badly marked in places, and near the kitchen it is peeling form the wall. The carpet is also in poor condition and is lifting away from the wall in places. Following a heavy downpour of rain the home had suffered from water penetration in several areas. Brenda said that on an earlier occasion the dining room ceiling had leaked. But this was now repaired. Water had come through the fire escape door on the ground floor. Towels had been placed around this to soak up the excess from the carpet. The ceiling in room 25 was leaking and the person in this room had been moved to another room. This had occurred two weeks earlier and the problem was not yet remedied. The home’s handyman was on holiday at this time but Brenda had reported this to the provider. Despite contractors having looked at the problem it was not resolved. Brenda said that this was the third time the room had had to be evacuated in the past ten months. Brenda confirmed that this mater had been addressed shortly after the visit to the service. One of the toilets on the first floor showed signs of water leaking onto the panel in the false ceiling around the automatic extractor, which was activated by the light switch. This was drawn to Brenda’s attention and the room was locked until an electrician attended to make sure that it was safe to use. Brenda said that there is an ongoing plan for redecoration. The fire escape and dining room window had been replaced and now needed to be painted. The handyman would be doing this on return from holiday. There is evidence that people who live at the home can personalise their rooms and even bring small items of furniture if they wish. One person commented that this was very important to her and was one of the reasons she chose the home. Where people need specialist equipment this has been obtained, for example one person uses a special bed. Waterloo House DS0000000639.V369526.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at the home will have their needs met by well recruited and trained staff. EVIDENCE: The home has low staff turnover. Only one member of staff has left in the past twelve months. One of the senior staff was on sick leave at the time of the visit and the home had a vacancy for a nighttime position. The manager was covering these vacancies from within the staff team and has used agency staff for cover on 14 shifts in the past three months. Five care staff were on duty at the time of the visit. Two cleaning staff, one of which was covering for the holiday leave of the laundry staff. One cook, one kitchen assistant. 85 of the care staff hold a national vocational qualification (NVQ) in care at level 2 or above. 15 are working towards this. One of the more recent staff to be recruited confirmed that they had received thorough induction and had been able to be take up NVQ training immediately after this. The domestic staff have undertaken NVQ training also. Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 20 The staff files were examined and these show that staff are able to take up the basic and further training opportunities related to the care of older people. The home uses a training agency and they can rely on the agency to update mandatory training as a matter of routine. The staff files are in good order and regular one to one supervision has been introduced. Some staff have yet to receive this. The records of this are well structured and they show that it is a two way process. Annual appraisals are also being carried out. Staff recruitment is a clear process. The files that were examined had evidence of full applications, clear recruitment checks, appropriate references and records of interviews. Waterloo House DS0000000639.V369526.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements keep service users safe. People living at the service are being consulted about how well the service is doing. Areas for improvement are identified but these take too long to be addressed. Some quality issues go overlooked and this detracts from the dignity of service users. EVIDENCE: Brenda Nicholson is registered with CSCI as the manager and holds the registered manager’s award. Brenda has held this position for eleven years and is well regarded among the staff team and the representatives of the people who use the service. Brenda has undertaken training recently related to care of Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 22 older people. But she does not have a personal training plan for the coming year. The home’s management structure does not provide Brenda with a designated deputy, or administrative support, but two of the senior staff deputise for her in her absence. Brenda reports to Mr Gill, the provider, and he appoints an employee to carry out monthly checks of the service on his behalf. Brenda can call upon the services of other businesses who are contracted with for routine servicing and repair of installations. Reports from these visits are produced and these include the views of the service users. As yet other people and agencies with an interest in the service have not been surveyed. Brenda said that she is hoping to re instate the residents/relatives committee. There is an annual quality check carried out, but this has not addressed matters to do with the upkeep of the building. Brenda said that she finds the length of time it takes to get agreement to fund major repairs to the building as a frustration for her. Also the lack of administrative support means that a lot of time is spent on manual administrative tasks that could be done in a more efficient way. For example Brenda was manually processing time sheets for the staff wages. Service user monies are held in a safe as separate amounts and individual account books are kept. Brenda had begun the monthly audit and had picked up some small discrepancies. But one account for a person who had been supported with shopping that day was short by in excess of £6. The staff member had made an entry for the total amount spent rather than itemised to each receipt and some receipts were lost. Some of the items were consumables and others were clothes. If these had been receipted for separately it would have been clearer for audit and for inventory purposes. The home has a written policy for handling service users’ money but this is not well written. It is not specific about how staff are expected to account for purchases. And policy statements are not separated from procedures. The home now has a computer and e-mail facility. This means that Brenda can access up to date guidance documents. But the computer does not have any programmes on it that could support the management and care processes. The home keeps records of care additional to the service user plans. These could be incorporated into the service user plans if pre-printed or electronic forms were used instead of hard backed books for example, and this would be more up-to-date practice in record keeping. Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 23 The handyman carries out the safety checks for the building, including the fire safety, water safety checks. These were up to date until the point of his annual leave. None of the weekly fire safety checks had been carried out during his leave. The home has up to date guidance to do with infection control. Most of this has been implemented, but there is more yet to do. There is not an action plan for this. There was no information about how many staff have received training in infection control. But one of the staff acts as liaison for the infection control team and can provide training and carry out audits. This person was on sick leave. Portable appliance tests had been carried out in July 2008. Lifts and hoists have been serviced this year. As have fire safety appliances and equipment. There are no dates for the testing of premises electrical circuits. One person said that the cutlery was not always clean. The kitchen assistant said that the dishwasher is working well but leaves watermarks on the cutlery. Some cutlery was found lying on a table in the activity room. The manager, Brenda said that this was for those people who take meals in their rooms on the second floor. A cutlery draw is not available in this room. Information provided by the manager shows that the home has assessments for hazardous substances and that staff have received training in food hygiene. The environmental health officer visited the service in 2007. There are no matters outstanding from this visit. The home does not have window restrictors on the first floor and risk assessments have not been carried out for provision of these. Waterloo House DS0000000639.V369526.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 2 x 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 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 2 x x x x x x 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 x 2 x 2 2 2 2 Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4,6, Requirement To continue to admit and care for people who have care needs that are not included in the categories of care for which the home is registered, the registered provider must make application to CSCI for a variation to the categories of care on the registration certificate. The manager must, in consultation with care managers, ensure that all service user plans clearly identify those service users who have been judged to lack capacity to consent. 30/06/08 not met 3. OP19 23 The registered provider must arrange for a full inspection of the roof and provide a report from this with a maintenance plan for any identified repairs. An action plan must be submitted with timescales for refurbishment of the dining room. 15/09/08 Timescale for action 31/12/08 2. OP7 15 30/11/08 4 OP26 23 31/10/08 Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 26 6. OP35 17 Schedule 4 The registered manager must revise and re issue to staff the procedure for handling service users’ monies to include clearer guidance for how staff are expected to account for each item of expenditure. The registered manager must provide formal supervision to all staff at the required intervals. The records to do with the care and the support of service users, must be reviewed so that it is maintained in good order and information is in one place, securely stored and easily audited. The manager’s role and training needs must be reviewed to ensure that the managers’ time is being spent appropriate to meeting the care needs of the service users. All care staff should have training in the use of wheelchairs. 30/06/08 deadline not met 31/10/08 7. OP36 18 30/11/08 8 OP37 17 30/11/08 9 OP37 12 (1) (a) 31/12/08 10 OP38 18,13(4)( b) 30/11/08 11 12 13 14 OP38 OP38 OP38 OP38 23 23 13 23 Arrangements must be made to have the premises electrical systems tested. Safety checks must be kept up to date. The five steps to infection control must be fully implemented. Window restrictors must be provided on the first floor based on an assessment of vulnerability of and risk to service users. 31/12/08 31/10/08 31/10/08 31/10/08 Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 27 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 OP7 Good Practice Recommendations All entries in service user plans should be dated and signed. Where agreements are reached with service users and/or their representatives to do with restrictions of choice in the best interests of the service user, these agreements should be fully recorded and signed by those entering into the agreement. Regular reviews should be held with all parties and also be fully recorded. The medication procedure should describe the action staff are expected to take when making hand written entries into the record. The arrangements for consent to treatment should be included in the medication record for each person. When staff have been assessed for competence in administering medications, the outcome should be recorded in the staff file. The provider should respond formally to the suggestions made by service users to do with the facilities and services at the home. Improve the landscaping to the flowerbeds and improve the patio by use of planters and some screening. Cutlery should be stored in drawers or other closed containers when not in use. Standardised service user planning systems should be considered so that duplication of information is avoided. 3. 4. 5. 6. 7. 8. 9. OP10 OP10 OP10 OP12 OP33 OP20 OP26 OP37 Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 © 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 Waterloo House DS0000000639.V369526.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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