Inspection on 14/05/07 for Waterfall House

This inspection was carried out on 14th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Waterfall House 26/06/06

Waterfall House 08/11/05

Waterfall House 14/06/05

Waterfall House 03/11/04

Waterfall House 24/05/04

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Townley Road, 2-3

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Tudor Lodge

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Delrose House Ltd

Clovelly House Residential Home Ltd

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Cherry Tree House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Waterfall House 363-365 Bowes Road London N11 1AA Lead Inspector Jane Ray Key Unannounced Inspection 14th May 2007 09:15 Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 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 Waterfall House DS0000010684.V333474.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 Adults 18-65. 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. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waterfall House Address 363-365 Bowes Road London N11 1AA 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) 020 8368 1710 020 8351 0485 Mr Haresh Dhunnoo Mrs Marina Dhunnoo Care Home 27 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (27) of places Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Not to exceed 18 Adults of either gender with a mental disorder, excluding learning disability or dementia (MD) at Waterfall House 363/365 Bowes Road, New Southgate, London, N11 1AA Not to exceed 4 Adults of either gender with a mental disorder, excluding learning disability or dementia (MD) at 24 Brookdale, New Southgate, London, N11 1BP (satellite) Not to exceed 5 Adults of either gender with a mental disorder, excluding learning disability or dementia (MD) at 26 Brookdale, New Southgate, London, N11 1BP (satellite) Eleven specified service users who are over 65 years of age may remain accommodated in 363/365 Bowes Road. The home must advise the regulating authority at such times as any of the specified service users vacate the homes. One specified service user who is over 65 years of age may remain accommodated in 26 Brookdale, Waterfall House. The home must advise the regulating authority at such times as any of the specified service users vacates the home. 26th June 2006 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Waterfall House is a care home registered to provide support and accommodation to 27 adults of either gender with mental health problems. The homes service user guide states that Waterfall House offers rehabilitation to those with a mental illness with a view to living an ordinary life in the community. Waterfall House consists of three separate units: 363/365 Bowes Road accommodating 18 service users, 24 Brookdale accommodating 4 service users and 26 Brookdale accommodating 5 service users. Twelve service users are over the age of 65. The building in Bowes Road consists of two-semi detached houses, which have been connected internally and extended to provide additional living space. 2426 Brookdale are both ordinary suburban semi-detached properties positioned next to each other and about five minutes walk from Bowes Road. The home was opened in 1988 with seven service users all around 50 years of age. In Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 5 1992, 24 Brookdale opened and a few years later 26 Brookdale was opened these homes are for more independent service users. Waterfall House is a home for life but service users can move on if they choose to. The properties have well maintained front and back gardens. Local shops and all other amenities are close by. Arnos Grove tube station is five minutes walk away. Bowes Road is staffed 24 hours a day, whilst the two houses in Brookdale are staffed for a few hours during the day and are unstaffed at night. Service users can contact Bowes Road for support if needed. At the time of the inspection there were 21 service users living in the service. The current range of fees in the home is from £277 - £442 a week. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 14 May 2007 and was unannounced. The inspection lasted for six hours and was the main annual inspection. The inspection looked at how the home was performing in terms of the key National Minimum Standards for Younger Adults and the associated regulations. The inspector was able to meet, speak to and observe the support given to the current people living in the home. The inspector was also able to spend time talking to the registered provider and manager and two members of care staff who were working in the home. The inspector did a tour of the premises and also looked at a range of records including service users records, staff files and health and safety documentation. What the service does well: The people living in the home benefit from a service that has experience in supporting people who have enduring mental health issues and offers a professional, stable and supportive environment for them to live. The residents all benefit from a comprehensive assessment and individual care plans that are regularly reviewed. These enable each persons individual needs to be met. The home has good working links with health care professionals including the mental health service that enables the people living in the home to be supported with their healthcare issues. The home welcomes relatives and other friends and supports residents to maintain relationships. The people living in the home all feel able and comfortable to express their views on how the home is working and anything they need or want to happen. The home operates professional policies and procedures including those relating to staff recruitment and management, health and safety and medication. These help to safeguard the residents. The homes are well located to enable the people living in the service to access local shops and other amenities. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? Nine of the twelve requirements made at the previous inspection have been met. These are as follows: • • • • • Each person living in the home has a contract that is signed and includes the correct fee. The residents are offered opportunities to carry out some independent living skills for themselves. The people living in the services, are supported by staff to go out and visit local amenities, if they are unable to do this on their own. The people living the homes are offered an opportunity to have a flexible routine according to their individual wishes. The adult protection procedure has been updated to include the correct reporting procedures. The staff team have been trained on the protection of vulnerable adults. Soap and hand towels were available in the toilets. Relatives and healthcare professionals have contributed to the quality assurance exercise. The staff have received fire safety training. • • • What they could do better: Fifteen requirements and four recommendations have been made at this inspection. Three requirements and one recommendation were made under the heading individual needs and choices. This is to ensure each person is supported to have a regular meeting with their care manager, to support the people living in the home to have regular meetings and to ensure that where staff hold cigarettes on behalf of the residents that this is agreed and recorded in their care plan. It was also recommended that the staff are supported to develop their key-working role. One requirement and one recommendation was made under the heading of lifestyle to ensure the people living in the home eat healthy and nutritious food and to support and train the staff to enable the people living in the home to develop their independent living skills. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 8 Two requirements were made under the heading of personal and healthcare to ensure staff have medication training updated where needed and to ensure the medication PRN guidelines are in place. A recommendation was made in the section concerns, complaints and protection to ensure that where the staff have received training on the protection of vulnerable adults that this is recorded in their staff training record. The section on the environment included two requirements including ensuring the improvements that are outstanding from the previous inspection are completed and ensuring the homes are kept warm enough at all times. In the section on staffing five requirements were made to ensure 50 of the staff have completed or are undertaking NVQ training, to have regular staff team meetings, to ensure the staff all have completed contracts of employment, to ensure all the staff have completed inductions and to support the staff through regular supervisions. Two requirements and one recommendation were made in the section called conduct and management of the home to carry out the annual quality assurance audit and to carry out fire drills at night as well as during the day. The recommendation is to check whether any of the staff need some of their health and safety training updated. 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. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2,3,4 and 5 were inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People using the service can be assured that their individual needs will be assessed and that the staff are trained to meet their needs particularly in terms of their mental health. EVIDENCE: I read the statement of purpose and service user guide prior to the inspection and both these documents are satisfactory. I inspected four case notes for people living in the homes and these all contained assessments prepared by the placing authorities and then assessments completed by the manager. This information provided a good basis for the care plans that were in place. I discussed the current needs of the people living in the home with the manager and the care staff. The main needs of the residents relate to their mental health. One person living in the home is developing dementia. Last Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 11 year the staff team received training on mental health that covered depression, alcoholism and schizophrenia. The staff are now doing a distance learning course on dementia. No new people have moved into any of the homes in the last year. One staff member when asked about the admission process for new residents said that they always visit the home as part of making a decision about whether they want to come to the service. I looked at the contracts between the home and the residents for four people who live in the services. They all had a contact in place that included all the necessary information and was correctly signed. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7,8 and 9 were inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living in the service will all be supported to have a care plan on which they will be consulted. The recording of restrictions particularly in relation to cigarettes held by staff for the residents, needs to be improved. The residents also need to be supported to have regular meetings so they can have an opportunity to express their views on the home and the service they receive. EVIDENCE: I inspected care plans for four people currently living in the homes. I also spoke to the staff about the care plans. All four of the people whose records were inspected had comprehensive care plans in place. These were clearly laid out and covered all aspects of each persons needs in a user-friendly language. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 13 The care plans reflected the changing needs of the residents and were amended as required. The care plans had all been reviewed in the last six months and the residents had been involved in this process. It was however noted that three of the four people whose case notes were inspected had not met with their care manager in the last year and some had not met them for three or four years. The staff were asked about their key working role and were able to describe how they helped people with their shopping. They did not however support people to attend healthcare appointments, attend review meetings or review the care plans. I read the risk assessments for the same four people who live in the home. It was possible to see that an effort had been made to identify areas of personal risk and look at how this can be managed without placing unnecessary restrictions on people. Where restrictions are needed, for example the staff needing to lock the inner front door for periods of time, the reasons for this are clearly recorded. A number of the people living in the services buy their cigarettes and hand them over to the staff to hold and distribute on their behalf. The arrangements for each person must be recorded and agreed. One person living in the home needs to have his clothes stored in another room and the reasons for this also need to be recorded and agreed with other professionals at a review meeting. The arrangements to support the people living in the home to manage their own finances were recorded in all of the care plans that were viewed. The manager told the inspector that none of the residents has an advocate but a number have relatives or friends who help them to express their views. The records of residents meetings were viewed and these had taken place in September 2006 and January 2007. These meetings would benefit from taking place on a more regular basis. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11,12,13,14,15,16 and 17 were inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living in the homes are able to use local amenities and see friends and family according to their individual wishes. The residents said how much they enjoyed the food but they could be enabled to eat a healthier diet. EVIDENCE: I was able to see a number of the people in the homes helping with practical tasks, for example one person helped to serve drinks and another helped with the washing up after lunch. One person told me how he helps to tidy his room and make his bed. Another said that he prepares his own drinks and gets himself a snack if he wants one. It was however observed that the staff could benefit from further training on how to support the residents to improve their daily living skills. One member of staff said she does “almost everything” for Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 15 the people living in the home and was very proud that everything was so clean and organised. I spoke to two people living in the home about how they chose to practice their religion. One said she was Hindu and goes to the temple with her daughter. She eats a vegetarian diet and is able to prepare her own food. Another person explained that he is Muslim and that he has certain food that he likes to eat and the staff prepare this for him. The manager explained that five of the residents go to the Catholic Church each week and one goes to a Church of England service. The manager explained that four of the people living in the home go to a day service, which meets the needs of people who have mental health issues. I spoke to two of the people who attend this service and they said they enjoyed it very much. The inspector could see that many of the people living in the home are very independent and can take themselves out shopping and use public transport. One person I spoke to said she did not feel able to go out on her own and the staff take her shopping. I could also see in two of the case notes that I read, that the staff go for walks with the residents and help them to go to the local shops. I was able to observe that some of the people living in the home enjoyed playing games and doing drawing. They also watched the television and listened to the radio. Several of the people I spoke to said how much they enjoyed seeing families and friends. They said that families are welcome to visit the home and some go to see their relatives. During the inspection one person had a brief visit from her daughter and one man was going out for the day to see his relatives. One man said he had friends from the day centre and they often visit him at the weekend or he goes to see them. The people I spoke to who live in the homes said that they were able to get up and go to bed when they wished to do so, although at Waterfall Road the breakfast is served at a set time. One person from Brookdale said he had stayed up till 1am last night to watch a film. One person who lives at Bowes Road said most people choose to go to bed early, which probably reflects the fact that they have come from institutionalized previous placements. I looked at the menu that is prepared with the residents. The home provides a cooked lunch and dinner and people can choose their own food if they don’t want what is available on the menu. The staff member preparing the lunch explained that two people are diabetic and will eat fruit as a desert. I noticed that a lot of the meals use high fat convenience food such as burgers, sausages, frozen pies and other frozen food such as fish in batter. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20 were inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that they will be assisted to access healthcare appointments to get the support they need. Medication systems within the homes are well organised. EVIDENCE: I observed during the inspection that the staff were supporting the people living in the home to receive personal care in a manner that preserved their privacy and dignity. I did observe that some people were wearing clothes that looked a bit worn. The manager explained that as most of the people living in the home were heavy smokers they often did not have money left to buy clothes or go to the hairdressers and so the manager has to buy them some basic clothing. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 17 I looked at the healthcare records for four of the people living in the home. They had all been supported to access a range of healthcare professionals including the GP, dentist, optician and other outpatient appointments according to their individual needs. In addition they were all being supported to have their weight checked on a monthly basis. The manager explained that the GP had made a referral for the person who is developing dementia to see an appropriate specialist. I looked at the medication, administration records and staff training records. The home uses a blister pack medication administration system. The medication is stored in a locked cupboard in the office at Bowes Road and in a lounge cupboard at Brookdale. The temperature of the cupboard is checked daily. The manager said that two of the residents at Brookdale are selfadministering their medication and this is reflected in their assessment. One resident has PRN procyclidine and there are still no clear guidelines in place for when and how this should be administered. The home records the medication received on the administration record and they keep a record of medication returned to the pharmacist. This means it is possible to have an audit trail for the medication. The medication administration records were correctly completed. The training records were checked for four staff and they had all received medication training, although one person had undertaken this training in 2003 and needs to have this updated. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that the correct training and procedures are in place to protect them from the risk of being abused. EVIDENCE: I looked at the record of complaints and whilst there have been no complaints since the last inspection an appropriate format is available to record complaints. I spoke to two people living in the home and they both said that if they had any problems they would complain to the staff or the manager. I observed that the home has a copy of the appropriate local authority adult protection procedure. There have been no adult protection issues since the last inspection. I looked at the staff training records for four members of staff. The manager explained that three staff had done adult protection training with the local council and she had passed on training to the rest of the staff team but not recorded this training. I spoke to staff about the protection of vulnerable adults and they both showed a good understanding of this topic. I saw the record of each of the people living in the home receiving and signing for their personal allowance. Each person then looks after their own money and this arrangement was confirmed by the people I spoke to. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24,25 and 30 were inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People living in the home can be assured that the environment will be clean and tidy as well as being maintained. The smaller houses are much more homely than the larger home at Bowes Road. EVIDENCE: I did a tour of the three homes. Since the previous inspection it was disappointing to note that no environmental improvements have taken place although the owner did explain that they are planning to extend the conservatory and this will them become the smoking area. Some areas for improvement identified at the previous inspection at Bowes Road include replacing the downstairs hallway carpet, replacing the strip lighting and providing more domestic lighting and providing a larger television Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 20 in the lounge to ensure it can be seen by the service users. These environmental improvements were restated. The homes were all observed to be extremely clean and tidy. The showers and toilets at Bowes Road were observed to have any soap and hand towels. In all the homes the lounges were found to be very cold. This was because the windows or patio doors were open to remove the cigarette smoke, rather than using the extractor fan. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32,33,34,35 and 36 were inspected. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The people living in the home are supported by a small team of staff, most of whom have worked at the service for a number of years. More staff would benefit from studying for an NVQ in care and their development could also be enhanced, by improving the standard and frequency of supervisions. EVIDENCE: The manager explained that there are 8 staff working at Waterfall House of which there is the registered manager, the registered provider, 5 care staff and 1 cleaner. The staff turnover is low and the manager explained that at the time of the inspection there was only one waking night and a part-time daytime care staff vacancy. The staffing levels consist of two care staff on the day shifts and one waking night staff at Bowes Road. In addition there is also one member of staff working for seven hours each day at Brookdale. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 22 I looked at the records of staff team meetings and these show that the discussions relate mainly to how the staff team are working together and their conduct. These meetings have not been taking place on a regular basis and could be used to discuss a wider range of operational issues, good practice and training issues. The manager explained that one member of staff has completed an NVQ in care and two staff are studying for the qualification. At least one more member of staff needs to study for the qualification to meet the minimum standard of 50 of the staff team having the qualification. I looked at the recruitment records for four staff. It was found that all the staff had two references, ID and a CRB disclosure. All the staff had a contract of employment but one did not include the rate of pay. I inspected the training records. I looked at the induction records for the four staff and two of these had no induction record available. The training record for each member of staff is found in their staff record. I looked at the supervision records for the four staff. They had all received individual supervision but this had not taken place on a regular basis with one member of staff not being supervised since October 2006. The supervisions discussed conduct and training but did not look at areas for improved performance such as how staff were performing their key-working roles. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37,39 and 42 were inspected. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users can be confident that the home is overseen by an experienced and appropriately qualified manager. Their health and safety is protected by the appropriate measures being in place. EVIDENCE: The service has a registered manager. The manager has the appropriate skills and experience and has also completed the NVQ level 4 in the management of care. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 24 The manager explained that a quality assurance exercise took place last year and I was able to the see the questionnaires that sought the views of the residents, relatives and care professionals. This exercise, which is undertaken on an annual basis now needs to be repeated. Fire safety measures are in place. The fire safety records were inspected in Bowes Road and Brookdale and weekly fire alarm checks and monthly fire drills are recorded. It was however noted that fire drills should take place at night as well as during the day. On the day of the inspection the fire doors in the home were closed. The fire alarm and extinguishers had received their service and records were available to confirm this had taken place. The home has a fire safety risk assessment and emergency plan. The training records for four staff were inspected and they had all received fire safety training. The certificates were in place to confirm the gas system and portable electrical appliances had been serviced in all the houses. The electrical installation certificate had just run out but the manager was already making arrangements to have this renewed. The current insurance certificate was displayed and was satisfactory. The staff training records were inspected for four staff and they had received appropriate health and safety training including first aid and food hygiene. Some of this training took place three years ago and may need to be updated. Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 3 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 3 x 2 x x x 2 Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 26 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 YA6 Regulation 15(2) Requirement The registered person must support each person living in the home to have a review meeting with their care manager on an annual basis. The registered person must support the people living in the home to have regular meetings so they have a forum for expressing their views on the operation of the service. The registered person must ensure that where staff hold the residents cigarettes on their behalf that this is recorded and agreed with each person concerned. The registered person must ensure the food eaten by the people in the home is healthy and nutritious and reduce the use of frozen convenience food. The registered person must update the staff training on medication where this is out of date. The registered person must ensure that the one service user who has PRN medication has guidelines in place stating when DS0000010684.V333474.R01.S.doc Timescale for action 31/08/07 2. YA8 12(2) 15/06/07 3. YA9 12(2) 30/06/07 4. YA17 16(2)(i) 30/06/07 5. YA20 13(2) 31/07/07 6. YA20 13(2) 31/07/07 Waterfall House Version 5.2 Page 27 7. 8. YA24 YA24 23(2)(p) 23(2)(b) 9. YA32 18(1)(c) 10. YA33 18(1)(c) 11. YA34 17(2) 12. YA35 18(1)(c) 13. YA36 18(2) 14. YA39 24(1)-(3) this medication should be administered. This requirement is restated from the previous inspection. Timescale of 31/07/06 was unmet. The registered person must ensure the home is kept warm at all times. The registered person must complete the building improvements identified in the environment section of the report. This requirement is restated from the previous inspection. Timescale of 30/09/06 was unmet. The registered person must ensure that at least 50 of the staff team have completed or are studying for an NVQ in care. The registered person must ensure that regular staff team meetings take place and that they are used to improve the standard of care and support by ensuring effective communication with the staff team. The registered person must ensure that all the staff have completed contracts of employment. This requirement is restated from the previous inspection. Timescale of 31/07/06 was unmet. The registered person must ensure all the staff have a completed induction training record. The registered person must ensure all the staff receive regular supervision and that this discusses how their performance can be improved. The registered person must undertake the quality assurance exercise for the current year. DS0000010684.V333474.R01.S.doc 15/06/07 30/09/07 31/07/07 30/06/07 30/06/07 31/07/07 30/06/07 31/07/07 Waterfall House Version 5.2 Page 28 15. YA42 23(4) The registered person must do fire drills at night as well as during the day. 30/06/07 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. Refer to Standard YA6 Good Practice Recommendations The registered person should support the staff to carry out a key working role that includes attending review meetings, taking the person for healthcare appointments and updating their care plans. The registered person should explore ways of developing the staff through training and supervision to work in a manner that enables the people living in the home to extend their daily living skills. The registered person should ensure that training given on adult protection is recorded in the staff training records. The registered person should check when staff need their health and safety training updated. 2. YA11 3. 4. YA23 YA42 Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Waterfall House DS0000010684.V333474.R01.S.doc Version 5.2 Page 30 - 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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