Inspection on 16/01/06 for Waterside

This inspection was carried out on 16th January 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

Waterside 11/06/07

Waterside 14/06/06

Waterside 08/09/05

Waterside 30/03/05

Waterside 16/08/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Waterside 40 Sumner Road London SE15 6LA Lead Inspector Sonia McKay Unannounced Inspection 16th January 2006 09.30 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 Waterside DS0000052132.V271785.R01.S.doc Version 5.0 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. Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Waterside Address 40 Sumner Road London SE15 6LA 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) 0207 358 5780 0208 652 1917 Anchor Trust Mr Ayobami Adeluola Care Home 49 Category(ies) of Old age, not falling within any other category registration, with number (49) of places Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th September 2005 Brief Description of the Service: Waterside residential home is a service that has been newly built by Anchor Housing to provide residential accommodation to Elderly People. The home has three floors and meets the current standards for residential accommodation. The home is in Peckham and has ample parking spaces situated at the rear of the home. Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by two inspectors, one of who is a CSCI pharmacist. The inspection took place over eight hours. It involved talking with service users, the new home manager, the manager of another Anchor home who has been providing management cover in recent months, staff, relatives and care and health professionals involved with the service. There was a tour of the premises. Records of care required and provided were examined and the inspectors had lunch with service users. This inspection focused on progress in meeting the requirements made as a result of the September 2005 inspection. Whilst the registered provider has formulated an action plan to meet these requirements, progress is limited. There have been management changes during this time. As a result, seven requirements are repeated in this report. The registered provider and the placing authority have met with the CSCI to develop plans to drive forward improvement in the services provided at Waterside. What the service does well: What has improved since the last inspection? Anchor now provides a member of staff with specialist skills in supporting the needs of service users with dementia. This staff member visits the home on a regular basis to provide carers with advice and to develop a better network of contacts with specialist health services in the area. A home manager has been recruited. The registered provider is taking steps to assess the dependency levels of individual service users with a view to providing increased staffing levels. Steps have also been taken to ensure that more staff have a vocational qualification in care. The passenger lift has undergone essential repairs and is now working well. Medication handling/storage, compliance and recording has improved since the last inspection due to the implementation of medication audits and Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 6 retraining/reduction in the number of staff authorised to administer medication (now only senior staff and management). What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 7 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 Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&5 Service users needs are not adequately documented and plans to meet identified care needs are incomplete. Changing and increasing care needs are not adequately addressed. EVIDENCE: The inspectors examined five care plans. Written information about the care needs of each individual is available, although a formal community care assessment is not available in all cases. For individuals referred through care management arrangements, the registered person must obtain a summary of the care management assessment and associated care plan to ensure that the care needs of the service user have been fully assessed by people trained to do so and can be adequately planned for and met by the home. The home also produces a care needs assessment. The care plans examined did not adequately cover all of the areas of identified need. Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 9 In the previous inspection reports of 30 March 2005 and 8 September 2005, a requirement was made for the home to provide evidence that care needs identified in placing authority community care assessments were met. Although some staff have recently attended training in effective care planning this requirement has not been fully addressed and is re-stated in this report. (See requirement 1). Additionally, one service user had recently been discharged from hospital back to the home. A discharge summary of needs was not available. His care needs had changed significantly and at the time of the inspection it was clear that there were concerns that the home was unable to meet his current needs. In these instances the home manager must take swift action to raise these issues with the hospital and placing authority prior to discharge. (See requirement 2) Service users have not been able to visit the home before moving in for a trial period. For some this was because they had been in hospital. In some cases relatives have visited the home on the service users behalf. This is not ideal and the home should consider ways to provide prospective service users with the opportunity to visit the home before they make a decision to move in. (See recommendation 1). Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Service users health, personal and social care needs are not set out clearly in their individual plans of care. Service users health needs are not fully identified or met. Although the home has a comprehensive medication policy and has provided medication training for staff, which includes a competence assessment, medication errors are still occurring, which place service users at risk as their medication needs are not always met. EVIDENCE: Written care plans are described as individual lifestyle agreements in individual records kept for each service user. These individual plans are stored in files and kept in the service users own bedrooms. Although there is useful information within these records, part of which is written as if the service user had written it themselves, pertinent information to enable staff to support the service user as they need and wish is not easily accessible. Information within these written documents is conflicting in some cases and the recorded processes for reviewing this information has not been followed. Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 11 The practice of keeping the sole copy of this information in service users own bedrooms should be reviewed to ensure that information is also readily available to staff on duty. (See recommendation 2) The care plans do not cover all the identified health, personal and social care needs identified in needs assessment information that is also held in the files. For example, one service user is assessed as needing a high protein and high calorie diet, although there is no care plan in place and records of meals eaten show that high calorie, high protein meals have not been provided. The service user has been prescribed a liquid meal supplement but has lost 10kg in weight in twelve months. Another service user is assessed as having dementia resulting in odd and at times extreme behaviour. There is no psychological care plan in place to address this need. (See requirement 1) A form to document the monthly review of care plans is in place but does not link to individual care plans in place for each service user. Dependency assessments available are conflicting in some cases and had not been reviewed regularly. Manual handling risk assessments had not been reviewed with the required frequency. (See requirement 3) Service users are asked what their preferred personal care routines are. For example, assistance with using the toilet and bathroom, getting dressed, getting up and going to bed. Although this information is available, it is not easily accessible to staff providing the support on a day-to-day basis and records of the support actually provided did not tally with the service users requests in all cases. For example, records available indicate that one service users have been supported to have a bath only once in a month. (See requirement 4) The care plans contained a section entitled people involved in providing care to each service user. This section did not contain the contact information for all health professionals involved in the care of each person, as would be expected. Specific plans to meet identified health care needs such as regular healthcare appointments are not in place (chiropody, audiology, ophthalmology, dental etc), although the outcomes of health appointments attended had been recorded. This is not conducive to pro-active and preventative healthcare for service users. (See requirement 5) Staff complete brief notes about the health and welfare of each service user at the end of every shift. The new home manager intends to introduce a more detailed account of staff observations for each shift. It is hoped that this will improve the quality and detail of recorded observations and ensure that notes Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 12 are maintained more effectively (there have been gaps in recording on occasion). A district nurse who visits eight of the service users said that care staff were pro-active in seeking professional help and advice from district nurses and GP services. Observations of interactions between care staff and service users had been noted to be friendly and respectful. Service users who commented said that staff treated them well and with respect. Service users are registered with three GP group practices in the area. This has led to difficulties for prospective service users and for staff in the home with regard to ongoing healthcare. The managing organisation is in discussion with the local PCT to ensure that all service users accommodated in the home can be automatically registered with one practice if they wish. There have been serious medication errors. The registered provider has responded by re-training nine members of staff and reducing the number of staff involved in administration to senior staff only. A qualified RMN also visits the home twice a week to assist staff to recognise and document side effects. The community pharmacist will also commence involvement with the home in January 2006. Medication stocks and records examined during this inspection resulted in an immediate requirement for the home to investigate further discrepancies. (See requirements 15, 16 & 18) Overall, the recording of administration has improved since the last inspection. There were very few instances of missed doses. Storage facilities have also improved, as the home now uses a medication trolley instead of dispensing from a cupboard outside each lounge and transporting medication to each resident. A medication profile has been implemented, which states what each medication is used for, and possible side effects. Although there have been improvements, there has been an unacceptable level of serious medication errors since June 2005, which continue to occur. The registered provider has responded by again re-training nine members of staff and reducing the number of staff involved in administration to senior staff only. A qualified RMN also visits the home twice a week to assist staff to recognise and document side-effects. The PCT pharmacist will also commence involvement with the home in January 2006. There are four areas that require improvement: • There were a number of prescribed items that were not in stock as supplies had run out. In some cases, the home had ordered a repeat prescription which had had not been received, but ultimately the health needs of these service users are not being met. (See requirement 13). Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 13 The receipt quantities of number of prescribed items had not been recorded on the Medication Administration Record (MAR) charts, therefore a justified stock check could not be carried out. (See requirement 14). Some members of staff have been signed off on a competence assessment which does not include all of the formulations and presentations of medication they are administering e.g. liquids, eye drops, ear drops. (See requirement 15). In one case staff were not administering a prescribed anti-diabetic medication according to the prescribers instructions, clearly stated on the MAR chart. (See requirement 16). • • • Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Although recreational activities are provided, the range should be increased and the activities should be facilitated by staff specifically trained to do so. Service users are able to maintain contact with family/friends/representatives and in some cases the local community. Service users are helped to exercise choice and control over their lives. Menu choices must be increased and include meals that meet the dietary and cultural needs and preferences of all service users. EVIDENCE: Service users have the opportunity to exercise their choice in relation to some routines of daily living. Their interests are recorded and there are opportunities for stimulation through leisure and recreational activities within and outside the home. For example, day trips to the seaside and other places of interest. An activities co-ordinator works with service users and staff in the home twice each week. Staff on duty facilitate a programme of weekday activities including bingo, karaoke, beauty parlour, knitting and arts and crafts, ball and board games and music and movement. The home manager is developing a wider range of activities and interest groups and has proposed a gardening club that service users are keen to be involved with. He is also compiling a set of old photographs of the local area for the reminiscence groups. Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 15 Many service users have increasing dementia. Life story work is recommended as a useful method of recording past interests and employment. Staff would also benefit from training in facilitating activities for service users with dementia. (See recommendations 3 & 4) A number of service users are Afro-Caribbean. It was not clear whether their cultural interests had been taken into consideration when planning activities. A recommendation is made for the home to appoint a named member of staff to co-ordinate activities and develop the range of activities available to ensure that the interests of all service users are included. (See recommendation 5). Service users are able to have visitors at any reasonable time. Visitors spoken with on the day of the inspection said that staff are welcoming and that they had enjoyed Christmas lunch with their relative. Staff had made a special effort by arranging an additional table for them to enjoy lunch all together. A payphone is available on each of the three floors of the home. The payphone can be wheeled into a service users bedroom and connected to a telephone line within the room to enable private calls. Service users said that they are able to open their own mail. Written records are stored in the bedrooms. Information about local advocacy groups is included in the service users’ guide to the home and is also available at reception. The inspectors joined the service users for lunch in one of the three communal dining areas. Meals are prepared in the main kitchen on the ground floor and transported to each floor of the home in heated trolleys. The meal consisted of a vegetable/chicken burger, mashed potato and diced vegetables with a choice of ginger cake and custard or fresh fruit for dessert. Portion sizes are adequate and the meal was served hot. Meals are served on a number of small dining tables. The mealtime was unhurried and service users were given sufficient time to eat. However, one service user experienced difficulty cutting up a chicken burger and soon abandoned eating the meal. Assistance was not offered. The daily log did not record that the service user had not eaten any lunch. A service user said that meals are OK . Adequate nutritional needs information was not available in the main kitchen during the late afternoon. The chef was not on duty and the only records available to the cook and assistant were on a notice board. These brief notes did not tally with nutritional needs assessments available in individual records. (See requirements 1 & 6) Written menus are available and were noted to contain a large quantity of processed meat. For example, supper on the day of the inspection was Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 16 another form of burger. Menus also contained many errors making them difficult to understand and did not include the cultural meal options noted on the main menu displayed by the ground floor reception. Alternative culturally appropriate meals are available at only two meal times each week. Comments recorded in a kitchen communication book show that service users had not enjoyed the meals provided on occasion, but there is no record of what action is taken as a result. (See recommendations 6 & 7) Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 17 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Formal complaints have been acted upon and taken seriously, although service users are not confident that their complaints are listened to on all occasions. Swift and effective action must be taken to ensure that service users are protected from all forms of abuse, including failure to provide adequate care. Staff must be better trained to recognise abuse and take appropriate action. EVIDENCE: The complaints procedure is circulated within the home and includes the option of contacting the CSCI, at any stage of the complaint, should a complainant wish to do so. Service users said that they feel confident to make a complaint to staff but that their concerns had not always been acted upon. More must be done to ensure that staff take note of these concerns, and if they are unable to act upon them themselves, to pass them on to senior staff or the home manager for consideration. (See recommendation 8). Procedures are in place to refer staff deemed to be unsuitable to work with vulnerable adults to the Protection of Vulnerable Adults list (POVA). One exmember of staff has been referred to the list in the last 12 months. Policies and procedures are in place for adult protection and the prevention of abuse, aggression towards staff, service users absconding or going missing from the home, physical intervention (restraint) and whistle-blowing. Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 18 Although some staff have been trained in managing aggression in the last 12 months, specific training in abuse awareness has not been provided. Part of the new staff induction programme includes reading a booklet about rights and responsibilities which includes a section on abuse. However, formal training is required. This will ensure that staff are fully aware of the different types of adult abuse and the signs to look out for. Better equipping them to recognise abuse and use the procedures in place in the home should they need to. (See requirement 7). There have been six adult protection investigations in the last 12 months. Outcomes from these investigations include the need to better monitor the health of service users in the home, the need for better communication between staff about the changing health needs of service users, prompt referral to medical professionals and safer administration of medication. The handling and administration of medication has been the subject of recent adult protection investigations. Medication handling has improved but there still areas that require improvement. (See medication requirements 13, 14, 15 & 16) Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 26 Service users live in a safe, well-maintained environment. They have access to safe and comfortable indoor communal facilities and outdoor spaces. There are suitable and sufficient lavatories and washing facilities and service users bedrooms are comfortable and personalised. The home is clean and pleasant. EVIDENCE: The location and layout of this purpose built home is suitable for its stated purpose. It is accessible, safe and well maintained, meeting service users individual and collective needs in a comfortable and homely way. There are three floors, each with a communal lounge and dining area. All communal areas are smoke free. Service users who wish to smoke can do so in their bedrooms or in the garden. Furnishings in the communal areas are domestic in character and of good quality. Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 20 The garden is wheelchair accessible. The grounds are kept tidy, safe, attractive and accessible to service users and they provide access to fresh air and sunlight. There is also a first floor roof terrace, although essential repairs being completed at the time of this inspection are preventing use of this area. Each service users bedroom has an en-suite toilet, hand washbasin and shower. Assisted communal bathrooms are available on each floor of the home, in addition to assisted shower rooms and WCs. Service users bedrooms are well furnished and homely. Each bedroom is fitted with an emergency call alarm system and low surface temperature radiators to prevent contact burns. The central heating in each bedroom can be adjusted to suit the service user. The home has one passenger lift. Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Although the registered provider is taking steps to ensure that service users needs are met by the numbers and skills mix of staff available, benefits that the required increased staffing levels and changes in skills mix will provide are not yet in place. EVIDENCE: The registered provider has introduced dependency needs monitoring of the current group of service users. The outcomes of these assessments are not yet available although the registered provider has acknowledged that there are increased dementia care needs. Two floors accommodate service users with significantly higher dependency levels. These are the Lavender and Bridgwater units, with lower care needs on the Avon unit. An Anchor RMN is working with staff in the home two days each week as a mental health development worker during this transition period. This aims to support care planning for people with dementia and develop networking with local mental health services. An additional senior carer is also floating between the three units of the home on three days each week to coach and support the team around personal care tasks. The provider is currently recruiting new staff and the proposed staff levels increase is due to come into effect in April 2006. (See requirement 8) Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 22 Key changes include: • Recruitment of a dedicated activities organiser • An increase in staffing levels and supervisor availability on each unit There is a shortage of care staff with an NVQ qualification. (See requirement 10). Members of the providers specialist care team have evaluated the training and development needs of the senior carers and the organisation is aiming to employ senior carers and carers who have already completed an NVQ. The staff training and development plan for 2006 must be supplied to the CSCI. (See requirement 9) A sample of recruitment records for staff currently employed were examined Although the required documentation was in place for three of the four members of staff, one file contained a CRB check from a previous employer and other files contained copies of CRB checks only. A manager explained that recruitment documents are obtained by a human resources department at the providers head office, and that original CRB checks are kept there. Copies of CRB checks on file in the home had been made from staff members original copies. The CSCI CRB policy has recently changed. This matter will be addressed with Anchor outside of this report. Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34, 36, 37 & 38 The new home manager is not yet registered with the CSCI and recent disruption in home management has been unsettling for staff, who have not been adequately supervised during this period. The registered provider has systems in place to monitor the quality of the service provided to service users and environmental safety issues are handled appropriately. EVIDENCE: Interim management arrangements have been put in place since the last inspection visit in September 2005. A manager from another home run by the registered provider has been acting as temporary home manager. A new home manager has been recruited and is currently undergoing an induction period. Both managers facilitated this inspection. The new home manager has a social work qualification and extensive experience in residential care services. He has yet to submit an application to Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 24 register with the CSCI as the home manager, but intends to do so at the end of his induction period (See requirement 11). Understandably this has been a difficult time for the staff team and it is hoped that, with a permanent manager now in post, essential leadership will be provided. Supervision meetings have not been held with the required frequency during this period. (See requirement 12). Records are maintained and stored securely and service users have access to their individual records. The registered provider undertakes various monitoring of the services provided by the home including quality inspection of hospitality services and unannounced visits in accordance with Regulation 26. Employers liability insurance is in place. Gas installations have been safety checked in April 2005. A pest control contract is in place and regular checks are conducted on the premises throughout the year. Hoists in user in the home have been safety checked in July 2005. A clinical waste contract is in place and the disposal of clinical waste is handled appropriately. Small electrical appliances have been safety tested in the August 2005. The fixed electrical wiring had been safety tested in May 2005. A local authority food hygiene inspection has been carried out in July 2005. The building is secure. Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 X 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 X X X 3 X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 X 3 X 1 3 3 Waterside DS0000052132.V271785.R01.S.doc Version 5.0 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 OP7OP3 Regulation 14 15 Requirement Timescale for action 31/03/06 2 OP3 12(1) 14 3 OP7 12(1) 14 15 4 OP7 12(1)(3) The registered person must ensure that the home can demonstrate that service users needs can be met. Further, that the service user plans address all needs identified in Community Care Assessments, completed by professionals from the purchasing authority, and any other professional assessments. Previous timescales of 30/04/05 and 30/11/05 not met. The registered person must 24/02/06 ensure that the home is able to fully meet the needs of any service user being discharged from hospital and re-admitted to the home. The registered person must 17/03/06 ensure that care plans and risk assessments are reviewed on a regular basis or when care needs change. Reviews must be documented. The registered person must 17/03/06 ensure that service users receive appropriate levels of support with personal care. DS0000052132.V271785.R01.S.doc Version 5.0 Waterside Page 27 5 OP8 12(1)(a) (b) 6 OP15 12(1) 7 OP18 12(1)(a) 13(6) 8 OP27 18(1)(a) 9 OP30OP27 18(1)(c) 10 OP28 18(1)(a) 11 OP31 9 12 Waterside OP36 18(2) The registered person must ensure that clear plans are in place to address service users health-care needs and that these needs are monitored on a daily basis. Previous timescale of 30/11/05 not met. The registered person must ensure that the nutritional needs of each service users are recorded and addressed. This must include the nature of any assistance required with eating a meal. The registered person must ensure that all staff receive training in abuse awareness. Previous timescale of 30/11/05 not met. The registered person must ensure that adequate staffing levels are maintained on each floor of the home at all times. Staffing levels must be reviewed to ensure that there are a sufficient number of staff to meet the needs of the service users. Although there is progress, this previous requirement of 11/11/05 is not yet fully met. The registered person must supply the CSCI Southwark office with the staff training and development plan for 2006 The registered person must ensure that a minimum ratio of 50 of care staff have an NVQ level 2 or equivalent. This ratio is inclusive of agency and relief staff. The registered person must ensure that the home manager submits an application to register with the CSCI. The registered person must DS0000052132.V271785.R01.S.doc 17/03/06 17/02/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 Page 28 Version 5.0 13 OP9 13(2) 14 OP9 13(2) 15 OP9 13(2) 16 OP9 13(2) ensure that staff are adequately supervised. Formal supervision meetings must take place at least six times a year. The registered person must ensure that all prescribed medication is in stock at all times to prevent missed doses, that prescriptions are ordered well in advance and that outstanding items are followed up with the GP or Pharmacy. Immediate requirement. Previous timescale of 08/09/05 not met. The registered person must ensure that all receipt quantities are recorded on the MAR chart, including quantities brought forward from the previous month and items received mid-cycle. Immediate requirement. Previous timescale of 08/09/05 not met. The registered person must ensure that staff undergo thorough, formal training in medication (which includes a competence assessment on all routes of administration and all presentations of medication used at the home) before being allowed to administer medication. Previous timescale of 08/09/05 not met. The registered person must ensure that all medication is administered according to the prescribers instructions. Immediate requirement. 17/01/06 17/01/06 17/02/06 17/01/06 Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 29 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 OP5 OP7 Good Practice Recommendations The registered person should consider ways in which prospective service users can be enabled to visit the home before making a decision to move in. The registered person should ensure that staff providing day-to-day care to service users have easy access to pertinent care plan information relating to each service user. The policy of storing the sole copy of the care plans in service users bedrooms should be reviewed. The registered person should consider introducing life story documents to enable staff to have a better understanding of leisure interests and past employment. The registered person should provide staff training in providing activities for service users with dementia. The registered person should appoint a fulltime activities coordinator and provide that person with appropriate training. The range of activities provided should take into account the cultural interests of all service users accommodated in the home. The registered person should review and reduce the quantity of processed food produce being served. The registered person should increase range and availability of culturally appropriate meals. The registered person should ensure that staff unable to act upon a verbal complaint/concern made by a service user, pass the complaint/concern on to a senior member of staff or the home manager for consideration. 3 4 5 OP12 OP12 OP12 6 7 8 OP15 OP15 OP16 Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 30 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 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 Waterside DS0000052132.V271785.R01.S.doc Version 5.0 Page 31 - 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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