Inspection on 10/12/08 for Waterhall Care Centre

This inspection was carried out on 10th December 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Waterhall Care Centre 18/03/10

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 20/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Waterhall Care Centre Fern Grove Bletchley Buckinghamshire MK2 3QH     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jane Handscombe     Date: 1 0 1 2 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. 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 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Waterhall Care Centre Fern Grove Bletchley Buckinghamshire MK2 3QH Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Miss Sarah Jean Hancock Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 56. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Old age, not falling within any other category (OP). Date of last inspection Brief description of the care home 56 0 Over 65 0 56 care home 56 Waterhall Healthcare Ltd Care Homes for Older People Page 4 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection of the service was an unannounced key inspection. A key inspection is one in which the key National Minimum Standards (NMS) those standards that the Commission considers to be the most important to service users well being, are assessed. The inspection took place on Wednesday 10th December 2008 and was undertaken by a Regulation Inspector who was accompanied by a Regulations Manager. It was a thorough look at how well the service is doing. We took into account information that we have received about the service in the form of the homes Annual Quality Assurance Assessment (AQAA) and any other information that we have received about Waterhall Care Centre since their registration in July 2008.. The AQAA is a self-assessment of Care Homes for Older People Page 5 of 30 how well the home feels they are meeting the standards of care for people living at the home. All registered homes and agencies must send us their AQAA each year. We asked the views of the people who use the service and other people seen during the inspection. A tour of the home was undertaken and we joined residents for lunch. A sample of service users care plans and records, medication records and staff recruitment files were looked at. This report summarises how well the home is meeting the NMS, through using the Key Lines of Regulatory Assessment (KLORA). The KLORA sets out the types of evidence that best describes the standard - excellent, good, adequate or poor - of the care and facilities provided for people living at Waterhall Care Centere. A judgement statement summarises each section (outcome group) in the report. The overall quality (star) rating is arrived at through a rules based approach, with the emphasis on three sections of the report that look at the safety and management of the home: Health and Personal Care, Complaints and Protection, and Management and Administration. We would like to thank all those who gave their time and help during the inspection process. Fees range from 415.23 pounds to 580.00 pounds per week. What the care home does well: What has improved since the last inspection? What they could do better: Whilst service users are happy with the care they receive at Waterhall Care Centre and of the staff who deliver the care, there are a number of areas highlighted within this report for which requirements and recommendations have been made: Ensure that all staff are recruited in line with required checks as outlined in Schedule 2 of The Care Homes Regulations 2001, to ensure only scrupulous persons work with service users. Ensure that training has been arranged and booked to ensure that all remaining staff are provided with the health and safety training which incorporates the Infection Control and First Aid training and ensure files provide evidence of appropriate induction training that has been undertaken to meet the needs of those using the service. Ensure that declarations within peoples care plans are signed appropriately to evidence that they have been provided with a service users guide detailing information about the home and the services that they offer. Undertake a regular audit of service users files to ensure that all documentation held within them is appropriately completed and signed. Review the menus on display and provide in a format which is accessible to all those using the service. The ratio of care staff to service users needs be determined according to the assessed needs of residents and a system operated for calculating staff numbers required, in accordance with guidance recommended by the Department of Health Care Homes for Older People Page 7 of 30 Where references are supplied on unheaded letterheads the registered person should follow these up for verification of authenticity. Following any accidents/incidents, these should be documented in a consistent manner detailing any actions taken and the resultant outcome. More focus should be placed on dementia training for staff to ensure that the service users needs are understood and met appropriately 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 set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 30 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this 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 provides good clear information, which is used by prospective residents to help them choose a home that is right for them. All residents have their care needs assessed before moving into the home. The home does not provide for intermediate care Evidence: The homes service user guide and statement of purpose, provides both prospective and current users of the service with detailed information about the services that are offered at the home. Prior to being offered a place, an assessment of needs is undertaken to ensure both parties are confident that their needs can be met at Waterhall Care Centre. Visits to the home are also arranged so that prospective users of the service and their family Care Homes for Older People Page 10 of 30 Evidence: members can meet with fellow users of the service, meet with staff members, view the facilities that are offered and gain a feel of the home prior to making a decision as to whether the home is suitable for their needs. Files viewed during this visit evidenced that a thorough assessment of needs is undertaken, by a suitably qualified person. Information sought covers personal care, physical health, mental health, behaviour, social and leisure needs, medical needs and nutritional needs. Where any risks are evident, a risk assessment is undertaken with actions documented how the risk is to be minimised. The information gathered is then used to form the basis of an individualised plan of care to meet the assessed needs. However, there were instances in which people had not signed the declarations, held within their files, evidencing that they had received a statement of purpose and service users guide. Likewise, all four files viewed did not contain any evidence to suggest that they had each been provided with a written contract/statement of terms and conditions, however it was later ascertained that these are held seperately and not within the service users care plans. Care Homes for Older People Page 11 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Every user of the service has a detailed care plan in which their care needs are identified and details the actions required to meet them. There is a robust medication policy in place and whilst poor procedures have been found to take place, the home has taken appropriate measures to ensure the safe handling, recording and storage of medications thereby protecting the service users health, safety and welfare. Evidence: A sample of care plans were examined and this was followed up by meeting with individual residents to confirm that their care needs were being met. On each occasion the care plans gave a good reflection of the person, their care needs and how these would be met. The plans were reviewed on a regular basis, and the daily records reflected the care given as set out in the individual care plans. Whilst touring the home, it was noted that peoples care records were being stored in unlocked trolleys and a requirement has been made within this report to address this matter and ensure that personal information about service users is securely stored, to safeguard Care Homes for Older People Page 12 of 30 Evidence: confidential information. Information provided within the AQAA informs us that residents and/or their representatives are involved in the care planning and reviewing process although this was not always evident within the homes documentation. There were instances in which people had not signed declarations evidencing that they had read, understood and agreed to their individual care plans. Risk assessments were found to be contained within those files viewed and where a risk was identified support plans were in place detailing the actions to be taken to minimise such risks, these covered areas to include moving and handling, pressure area care, falls, ability to self medicate and nutrition, however these were not always signed and dated appropriately. Likewise, we noted that where the service user had the use of bedsides evidence was not always within the file to suggest that relevant discussions had taken place over their use and consent gained and neither was a rationale for their use in place. A recommendation has been made within this report to address this issue. The home has good working relationships with the local GPs and community health services and accesses them when appropriate. Evidence of any healthcare treatment, which service users receive, was found to be detailed within their care plans. As part of the inspection process we looked at the medication systems within the home and found them to be stored safely, securely and appropriately. There were one or two occasions in which gaps were found on the medication administration records where staff had not signed to evidence that the medications had been administered or that the person had in fact refused the medication. We discussed this with the manager of the home who informed us that a recent medication audit had been undertaken over four days at the beginning of the month and highlighted the same issue as well as some further issues ranging from the lack of some information being documented, medication not being booked in at the time that it is received into the home, handwritten entries on the administration records failing to have two signatures and some incidences in which the medication in stock did not tally with that on the MAR sheets. We were given access to the medication audit and advised that immediate actions had been taken to rectify the issues and further training was arranged for staff to attend and action plans were in place to ensure that the recording, safe handling and administration of medication served to protect the health, safety and welfare of the service users. The medication audit seen evidenced that a thorough audit had been undertaken and the home was dealing with the issues appropriately and thus working in the best interests of those using the service, to ensure their safety at all times Care Homes for Older People Page 13 of 30 Care Homes for Older People Page 14 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a choice of interesting, stimulating, therapeutic daily activities provided in both group sessions and a one to one basis for people to attend if they require. The meal provision is good offering choice and variety and catering for any special dietary needs. Evidence: The home has recently employed an activities co-ordinator who provides a varied programme of daily activities which provides people with the option to partake in stimulating, therapeutic, interesting activities if they wish. Activities are offered both in group sessions and on a one to one basis to suit the needs of the service users. The activities on offer the week of our visit were based around the theme of Christmas and included bingo, art and craft where users will be making Christmas decorations, attending a local school to watch a movie, a local church was attending the home to sing christmas carols which people can join in if they desire and an outside entertainer had been arranged to provide entertainment. A monthly service is offered by a local church who visits the home on a monthly basis providing hymns and prayers for people to attend if required and there is a visiting hairdresser who visits the home Care Homes for Older People Page 15 of 30 Evidence: once a week for those who require. People using the service are encouraged to maintain contact with their families, friends and their local community. Service users are able to receive visitors at the home and there are no restrictions imposed on visiting unless requested by the service user themselves. Service users are able to entertain them in their own bedrooms or in the communal areas of the home and meals can be provided for visitors who visit during mealtimes if required. Residents are provided with food, which is freshly cooked on the premises and are offered a choice. Special diets are available to meet peoples health and cultural needs and the chef always endeavours to take individual tastes into account and discusses their requirements. The home operates a four-week menu, which is reviewed seasonally with alternatives made available to allow users a choice. During our visit, we chose to take lunch with those using the service and found the dining environment to be relaxed and comfortable and people were able to enjoy their lunch at their own pace. There was a menu displayed in the dining room however this proved very difficult to read for both the service users and ourselves; it is recommended that this is reviewed and provided in an accessible format. As part of our inspection process we viewed the kitchen which was found to be well organised and kept to a clean standard of hygiene; food stocks were good and all relevant checks were being maintained and documented. Menu records were seen and discussed with the chef and a reccommendation was made to record any deviations from the menu to allow for an audit trial if required. The chef confirmed that the users of the service are involved in the planning of menus to ensure that their likes and dislikes are taken into account. Feedback from those using the service were all very complimentary around the provision and choice of food. Care Homes for Older People Page 16 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this 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 has a satisfactory complaints policy and complaints are taken seriously and acted upon appropriately. The home has safeguarding procedures in place to protect residents from any harm arising from their care. Evidence: Discussions with service users, family members and visitors to the home, informed us that they were aware of how to make a complaint if the need arose. They said that they were confident that any complaint made would be taken seriously and acted upon appropriately. Whilst touring the home it was noted that the complaints procedure was displayed on the noticeboards throughout the home for users of the service, their family members and visitors to the home to access should the need arise. The Commission for Social Care Inspection has not received any complaints about the home. Discussions with the manager ascertained that there have been three complaints made to the service itself, all of which we saw to have been documented in the services complaints book and dealt with appropriately. It was noted that the service had failed to document the outcome for one of the complaints and we were assured that this would be undertaken. There are policies and procedures in place to safeguard users of the service from abuse and to guide the manager and staff on how to respond to any suspicion of any Care Homes for Older People Page 17 of 30 Evidence: allegations or incidences. Training is provided to all members of staff to assist them in becoming aware of their own care practices, to recognise signs and symptoms of abuse and to emphasise each staff members responsibility to whistle blow on any poor practice or concerns that come to their attention. Since registration, there has been one safeguarding incidence, which was investigated appropriately using a multi disciplinary approach. There has been no need for any referrals to be made to the Protection of Vulnerable adults (POVA) list Care Homes for Older People Page 18 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this 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 standard of the environment within this home is good and provides residents with clean, attractive and comfortable accommodation. Evidence: Waterhall Care Centre is purpose built and provides a light, spacious and attractive environment. The residents spoken with are very pleased with the home and their individual rooms, with en-suite facilities, and the privacy that these provide. People are encouraged to personalise their own rooms with personal memorabilia if they require, this was confirmed by users of the service and evident whilst visiting people in their rooms during this visit. Residents spoken to on the day informed us that they were happy with their bedrooms and their surroundings, that the home is kept to a high standard of cleanliness at all times. People using the service are enabled to access their communal and private space, with the provision of a number of aids and adaptations where required. The home provides grab rails in corridors, bathrooms and toilets and hoists and assisted toilets and baths are available to meet the residents needs. The home has sufficient toilet, washing and bathing facilities, all of which were accessible and clearly marked. We viewed the laundry and found it to be well equipped, clean and tidy. The systems Care Homes for Older People Page 19 of 30 Evidence: for separation of soiled and clean laundry work are good and designed to reduce the risk of cross-contamination Service users spoken to during this visit were happy with the laundry service provided. Care Homes for Older People Page 20 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are some poor practices taking place around some aspects of staff recruitment and staff training which could compromise the health, safety and welfare of those using the service Evidence: The staffing levels on the day of inspection were sufficient to meet the needs of the residents. However feedback from completed questionnaires sent out to staff, service users and visiting healthcare professionals inform us that this is not always the case ; that there is not always enough staff on duty to meet the needs of the service users, this feedback from healthcare professionals was with particular reference to the dementia unit. During our visit it was noted that one service user was very anxious, from speaking with this individual it transpired that this particular individual was anxious due to being unable to communicate since he/she was not wearing his/her hearing aid. Staff appeared unaware that this individual used a hearing aid and when the service user produced it from her handbag and the staff attended to her need, the anxiety was removed. From observation on the dementia unit there was very little interraction with the service users and staff members were not seen to be very receptive. We fed back to the manager of the service and reccommended that there be more focus on dementia training for staff to ensure that the service users needs are understood and met appropriately. It is also recommended that a dependency level Care Homes for Older People Page 21 of 30 Evidence: check is undertaken and the home be staffed accordingly to ensure that the staffing levels within the home are appropriate to meet the needs of those using the service.. The home has recruitment procedures in place to ensure that suitable staff are employed to look after their vulnerable clients in which application forms are completed, references are collected and face-to-face interviews are undertaken. We are informed that relevant POVA (protection of vulnerable adults) and CRB (criminal records bureau) checks are undertaken to ensure the persons suitability with working with vulnerable people prior to a person being offered a position of employment, however poor practice in this area was evident during this visit. Five staff files were sampled for inspection which contained some shortfalls that need addressing. Evidence of CRB disclosures were not seen on three of the staff personnel files viewed and one of the remaining two files failed to evidence at what level the disclosure had been applied for, however we were assured that the full CRB forms are kept in a seperate file in the administrators office. Whilst viewing staff files it was noted that whilst references are sought those without a company stamp or letterhead are not always followed up for verification of authenticity. Each staff file contained an interview score sheet, however these were found to have been left blank and not completed. All five files failed to evidence that the staff had been provided with a contract of employment although the manager informed us that she was aware of the missing contracts of employment and had written to staff requesting they return them. Three of the files viewed failed to contain a photograph of the staff member. We are informed that all newly appointed members of staff undergo induction training upon appointment to their posts, and are provided with mandatory training, offered ongoing training and encouraged to undertake the National Vocational Qualification (NVQ) in Care, which equips them to meet the assessed needs of the residents within the home and allow for personal development. However, poor recording was evident in the files viewed. One staff members file contained an induction training certificate, which had not been signed appropriately by the trainer, two further staff files contained induction checklists but these had not been signed off and were totally blank and a further member of staffs file did not contain any evidence to suggest that an induction had been provided. We discussed the issue of induction training with the manager, who informed us that staff had taken their completed induction workbooks home and a letter had been sent out asking them to return them. There was evidence on the staff files seen, that madatory training had been undertaken but did not evidence that they had been provided with first aid or infection control. The manager has since informed us that the mandatory health and safety training incorporates a basic first aid module and one covering infection control of which 80 per cent of the Care Homes for Older People Page 22 of 30 Evidence: staff have completed. Information provided to us in the completed AQAA informs us that of the 16 permanent care staff six have obtained their NVQ qualifications at level 2 or above in care. There is a good feeling of teamwork amongst all the staff and those spoken to are very happy to be working at the home. Care Homes for Older People Page 23 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this 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 well managed and the quality of care for residents is monitored regularly by the organisation. There are health and safety systems in place to protect residents and staff from harm arising from their care, although there is evidence of poor recording and practices around the recruitment of staff and staff training which could compromise their health and safety. Evidence: The manager of Waterhall Care Centre is presently undergoing registration with the Commission for Social Care Inspection, she has over 20 years experience in nursing care and management and continues to update her knowledge and skills; during the last 12 months she has undertaken training covering health and safety in the work place, medication, safeguarding vulnerable adults and the mental capacity act. She has the required experience,knowledge and skills to manage the service competently. The home does not act as agent or manage monies on behalf of residents. Care Homes for Older People Page 24 of 30 Evidence: We discussed health and safety issues and saw maintenance records relating to maintaining a safe environment for residents. Regular safety checks are undertaken relating to fire safety and infectious diseases and regular servicing and maintenance of equipment. All accidents, injuries and incidents of illness or communicable disease are recorded and reported although there was evidence of inconsistences in follow ups from any accidents. It is reccommended that where accidents or incidences have been reported the follow up of any such incidences be followed up and documented in a consistent manner to provide an overall picture of any actions taken and the resulting outcome. The home engages regularly with users of the service to gain feedback on the service it provides through residents meetings, relatives meetings, both of which are minuted and through out of hours manager surgeries to which service users, relatives and staff can meet with the manager to discuss any aspects of the service or the care provision. The service also undertake regular audits on various aspects of the service, from which action plans are drawn up detailing any areas that need attending to, with dates for completion. Two recent audits which we were given access included that of a comprehensive medication audit and one which covered the auditing of staff personnel files. The home deals with a number of diverse care needs and always ensures to offer a personalised service to meet the needs of their clients. There is a commitment to ensure that all clients, however diverse their needs may be, receive a person-centred package of care which meets their needs appropriately. However a number of requirements have been made within this report, namely around staff recruitment and training to ensure the health, safety and welfare of those using the service. During our visit it was evident that records are generally up to date although some gaps are found in recording and entries are not always clear for which requirements/reccommendations have been made within the relevant sections of the report. Care Homes for Older People Page 25 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 17 Ensure that personal information about service users is securely stored, to safeguard confidential information. Regulation 17(1)b of the Care Homes Regulations 2001 requires (1) The registered person shalla) maintain in respect of each service user a record which includes the information, documents and other records specified in Schedule 3 relating to the service user; (b) ensure that the record referred to in sub-paragraph (a) is kept securely in the care home. 31/01/2009 2 29 19 Ensure that all staff are recruited in line with required checks as outlined in Schedule 2 of The Care Homes Regulations 2001, to ensure only scrupulous 31/01/2009 Care Homes for Older People Page 27 of 30 persons work with service users. Regulation 19 (1) of the Care Homes Regulations 2001 requires that the registered person shall not employ a person to work at the care home unlessa) the person is fit to work at the care home b) subject to paragraphs (6), (8) and (9) he has obtained in respect of that person the information and documents specified in paragraphs 1 to 9 of Schedule 2. 3 30 18 Ensure that training has been arranged and booked to ensure that all remaining staff are provided with health and safety training which incorporates the Infection Control and First Aid training and ensure files provide evidence of appropriate induction training that has been undertaken to meet the needs of those using the service. Regulation 18(1)(c) of the Care Homes Regulations 2001 requires (1) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users(c)ensure that the persons employed by the registered 31/01/2009 Care Homes for Older People Page 28 of 30 person to work at the care home receive (i) training appropriate to the work they are to perform (including structured induction training) Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 1 Ensure that declarations within peoples care plans are signed appropriately to evidence that they have been provided with a service users guide detailing information about the home and the services that they offer. Undertake a regular audit of service users files to ensure that all documentation held within them is appropriately completed and signed. Review the menus on display and provide in a format which is accessible to all those using the service. The ratio of care staff to service users needs be determined according to the assessed needs of residents and a system operated for calculating staff numbers required, in accordance with guidance recommended by the Department of Health Where references are supplied on unheaded letterheads the registered person should follow these up for verification of authenticity. It would be good practice to undertake an audit of staff personnel files to ensure that all the required documentation is held within them and is appropriately completed and signed It is reccommended that more focus is placed on dementia training for staff to ensure that the service users needs are understood and met appropriately It is recommended that following any accidents/incidents, these be documented in a consistent manner detailing any actions taken and the resultant outcome. 2 7 3 4 15 27 5 29 6 30 7 30 8 38 Care Homes for Older People Page 29 of 30 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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