Inspection on 19/07/07 for Watermill House

This inspection was carried out on 19th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Watermill House 08/07/09

Watermill House 12/07/06

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Watermill House Common Road Wressle North Lincolnshire DN20 0DH Lead Inspector Stephen Robertshaw Unannounced Inspection 19th July 2007 09:30 Watermill House DS0000066605.V346614.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 Watermill House DS0000066605.V346614.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. Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Watermill House Address Common Road Wressle North Lincolnshire DN20 0DH 01652 652147 F/P 01652 655766 helenh@roxbyhouse.co.uk www.optionsgroup.co.uk Wider Options Ltd 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) Helen Elizabeth Horsewood Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th July 2006 Brief Description of the Service: Watermill House provides accommodation for up to nine service users who have Autism Spectrum disorders and associated challenging behaviours. The original registration last year was for five service users; however, a new development on the site has been approved by the Commission to increase the registration to nine. The accommodation includes extensive grounds for the service users to access and horses are stabled on the premises. The service users also access services available at Watermill’s sister home Roxby House. Similar services are currently being developed at Watermill but they have not yet been completed. This includes therapeutic areas including a gym and a water spa. The current fees for the home are between £2760.33 and £3475.24 per week. There are no other fees incurred by the service users at the home. The fees include a weekly allowance for individual service users’ food, personal hygiene needs and activities. Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit to the home was unannounced and took place on 19th July 2007. The inspector was at Watermill House for approximately six hours. During this time the inspector observed case file information and staff interacting with the service users. The inspector also spoke with management, four care staff and three service users. Other information that was received by the Commission since the last inspection has also been used in determining the outcomes of this report. The inspector also had contact with three outside professional that are involved in supporting the personal and healthcare needs of the service users at Watermill House. The manager of the home had also completed and returned an annual Quality Assurance Assessment to the Commission and surveys were sent out to all of the service users and the staff group. What the service does well: What has improved since the last inspection? The staff are very positive to training especially NVQ, specialist autism and learning disability training. This means that they have a better understanding of how to communicate with the service users and this helps them to understand what care the service users need. Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 7 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 Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 8 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): 2,3,4 and 5 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This means that the service users are provided with very good information about the home before they are invited to visit the service to see if it would be suitable to them. EVIDENCE: At the time of the site visit there were six service users living at watermill House. The inspector case tracked two of the service users that were resident at the home. Both files clearly evidenced that the service users had been provided with detailed information in relation to the services that would be available to them if they lived at the home and a full assessment of their needs had been undertaken to make sure that the home could meet their individual needs. The assessments of needs were a combination of the assessment completed by the funding authorities and specialist psychiatry and psychology assessments that had been completed through the homes specialist departments and these were also supported by previous educational reports and the psychology and psychiatry input for individual service users in their previous placements. Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 9 The home had also completed a very comprehensive assessment of needs for the individual service users before they had been admitted to the home. It was evident that other people had been given the opportunity to air their views through these assessments and this included the service users families or legal representatives. Watermill House clearly has the capacity to meet the needs of the service users that live there. This evidence was supported through the inspector’s observations of the interactions between the service users, each other and with the staff group. The staff training profiles also supported that they receive the appropriate training to make sure that they fully understand the needs of the service users and recognise how they should be supported with their individual needs. Once the assessments have been completed the service users are invited to visit the home. These introduction visits range from a couple of hours to overnight stays to allow them to get used to the home, the other service users and the staff. Although the home has a policy and procedure to cover emergency admission it is not expected that anyone would be admitted to the home in an emergency situation as the assessment process is very complex and individuals need to be provided with time to adjust to their new situation and environment. All of the service users care files seen by the inspector included a contact with the home detailing the services that would be provided to them and the fess applicable to their care. The files also included a copy of the funding authorities agreement with the service to provide care to the individual service users. Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 10 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): 6,7,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service users are provided with choice in relation to how their needs are met at the home. EVIDENCE: The inspector case tracked two of the service users living at the home. Both of their care files included detailed care plans that had been developed from the original needs that were identified in their original assessments. Any changes in the service users needs had been identified and new care plans had been developed to meet these needs. The homes care plans seen by the inspector reflected the needs identified in the service users care management care plans. The care plans also included any restrictions that were in position for individual service users and these were supported through clear risk assessments. An example of this was a service users poor awareness of traffic and limitations of being allowed in to public areas unescorted due to anxieties in public places. Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 11 The care files seen by the inspector provided evidence that their families and social workers are invited to the home for any formal reviews of their care plans. The service users cultural and religious needs were also identified. The service users were observed working within their care plans and appeared to be very happy with them. The verbal communication of the majority of the service users in the home was very limited therefore it was difficult to obtain their opinions in relation to the care that they received except through direct observation and monitoring of their facial and body postures. Daily care plans are supported with pictorial plans for the service users to understand them better and to help them to understand what they are expected to be doing at any time as part of their personal development. Service users are supported wherever possible to make decisions for themselves in relation to their personal lives at the home. This was observed to include what to eat at mealtimes and what to do as part of their activity programme. Staff were observed working with the service users and using high levels of professionalism and care when encouraging the service users to follow their individual learning plans. The service users at the home did not generally have the capacity to care for their own finances, however their financial records were clearly recorded and where appropriate the person who was responsible for their finances was identified. On the two care files seen by the inspector, the manager of the home had been identified as the Department of Work and Pensions appointee for the service user as they had no other legal representative and the care management team had recommended this appointment. The service users are limited in how they can participate in the day-to-day running of the home due to their learning difficulties. All of the care plans seen by the inspector were supported where appropriate by clear risk assessments. The staff interviewed by the inspector were all aware of the individual risks that were presented by individual service users and understood what needed to be done to reduce the risks to the service users or others around them. The care files also included the service users brief details in case of any unexplained absence from the home and the need to inform the appropriate authorities including the police. All of the service users information that is stored at the home was held in accordance with the Data Protection Act 1988. Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 12 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): 11,12,13,14,15,16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This means that the service seers are encouraged to develop their personal lifestyles at the home. EVIDENCE: The service users care files observed by the inspector provided written evidence of the services users contact with their families and friends and showed how they are supported and are encouraged to maintain and develop their personal, emotional, communication and independent living skills. Although most of the service users do not have the capacity to safely move on to independent living the home supports them to be as independent as possible in line with the individual service users own abilities. None of the service users at the home had the capacity to find and maintain employment, however their individual care plans supported the service users Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 13 to continue with their education and training and to take part in fulfilling activities. The care files also included copies of any certificates of achievement that the service users had obtained whilst they were living at Watermill House. The service users are provided with a weekly allowance from their funding to pay for their activities and food and the service users are involved in deciding how this money is spent. Watermill house is within its own grouts and has developed since it was first built. A craft room has been included and a water spa, however a new water cleansing system needs to be fitted to the spa before it will be operational. These areas can be used with individual service users to decrease any behavioural problems that they may be experiencing or as a way for them to ‘chill out’. The service users are encouraged to access the local community and on the day of the site visit two of the service users individually accessed the community with support from the homes staff. This was observed to be as a direct request from the individual service users. Staff stated to the inspector that they encouraged the service users to access the local community whenever it was safe to do so. Every year the service users have a holiday made available to them. This has included individual service users and group holidays. Due to the nature and degree of the problems experienced the holidays had previously been only for two or three days. However this year a weeklong holiday is planned to go to Centre Parks. It is hoped that due to all of the activities that are available that this will be more appropriate to the needs of the service users. Two service users will not be attending the holiday due to their personal anxieties and alternative arrangements will be made for them to experience a holiday, or a break from their traditional weekly routines. The service users are encouraged to maintain contact with their families and friends. An example of this is one of the service users has a care provided through mobility allowances and this can be used to pick up his family and bring them to visit him, or alternatively take him to visit his family or to access other activities in the wider community. Mealtimes in the home were observed to be very flexible and were relaxed. The service users are encouraged to follow a healthy diet and any special diets are adhered to. The service users receive a weekly allowance for their food and activities and the care staff take them to the local shops and supermarkets to buy the ingredients for their meals. Where appropriate the service users are supported and encouraged to make meals for themselves and their peers, however where this is not appropriate the service users are encouraged to help prepare the ingredients for the meal and clear up the kitchen when this has been finished and wash the dirty dishes. Although there were service users in Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 14 the home with different cultural needs it was recognised in their assessments that this did not include and special diets. The inspector ate lunch with one of the service users and although they were none vocal it was obvious that they were enjoying their meal. The member of staff on duty stated that the service user ‘liked their food’ and there was very little that they didn’t like. The activity records are also cross-referenced with the service users daily diary notes. Some of these records could be improved through further development. Currently pictures of happy or sad faces are used to recognise the mood of the service user while they are taking part in activities and do not give any indication of why they are in that frame of mind and what supported them to become more relaxed if they had been anxious. The home has clear policies and procedures to support service users if they wish to develop or maintain intimate personal relationships with people of their choice. The daily routines for the service users the home helps to promote their independence and freedom of movement. Any restrictions in the movement of individual service users were supported through a clear risk assessment process and had been agreed through a multi disciplinary assessment. Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 15 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): 18,19,20 and 21 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This means that the home supports all of the personal and healthcare needs of the service users. EVIDENCE: The home does not provide nursing care to the service users. However their care records supported that when they have any healthcare needs they are seen by the appropriate professional, this included GP’s. psychologists, psychiatrists and community nurses. Dentists and opticians also visit the home to see the service users if they do not have the ability to access them in the community. Direct observations also showed the inspector that the privacy and dignity of the service users is upheld at all times in the home. Service users independence is also encouraged at all times and this included decorating their personal rooms to their own tastes and preferences. Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 16 The care files for the service users seen by the inspector showed that they did not have the capacity to safely administer their own prescribed medication. All of the care staff that administer medication in the home had received accredited medication training. Since the last inspection there had only been one reported medication error and fortunately this did not have any adverse effect on the service user involved and involved medication being received at the wrong time. The member of staff concerned was provided with refresher medication training provided through the deputy manager of the home. The service users medication is provided through a local pharmacy in monitored dosage containers. There were no controlled drugs in the home at the time of the site visit, however the service did have appropriate storage and recording facilities for controlled drugs. The Medication Administration Record sheets were all up to date and had been accurately recorded. Both of the care files observed by the inspector included their or their families feelings for their last wishes in the event of their deaths and the religious ceremonies and customs that should be followed. The care files also showed that all of the service users also include an annual health care check to make sure that they are healthy. Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 17 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): 22,23 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. This means that the service users are supported to raise any concerns that they have and that they are protected from abusive situations at the home. EVIDENCE: The returned Annual Quality Assurance Assessment supported the complaints and protection records in the home that no complaints or protection issues have been raised at the home since the last inspection. The home has a clear complaints procedure for the staff and the service users. The procedure has also been reproduced in picture format to make it easier for the service users to understand. The services logs for safeguarding adults have room for telephone conversations and minutes from meetings to be recorded. All of the staff receive safeguarding adults training to make sure that they can protect the service users. They also receive appropriate security vetting before they are employed to work at the home to make sure that they do not pose any threat to the service users. Staff training records and interviews with staff supported that they receive this training and that they are checked for their security before they have any contact with the service users. Staff also receive training to support young people with challenging behaviours to make sure that nobody is hurt or abused. The training they receive is called Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 18 Protecting Rights in a Caring Environment (PRICE). Since the last inspection there were no restraints recorded for any service users at the home. The care staffs induction training now also includes the Learning Disability Accredited Framework (LDAF) induction and foundation standards. The service users finances that are held in the home are monitored at the beginning/end of each shift by the team leaders to make sure that there are no discrepancies and that all transactions have been accurately recorded. Watermill House DS0000066605.V346614.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): 24,25,26,27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that generally the environment is suitable to meet the needs of the service users, however there are some areas of the environment that require attention. EVIDENCE: The inspector made a tour of the premises and found it to be suitable for its stated purpose and was safe and well maintained. There is a choice of communal areas for the service users to use to be either on their own or to be with their peers, or families and friends when they visit. The home was free from any offensive smells and was decorated and furnished to domestic standards. The grounds of the home are safely contained with barriers to ensure the health and safety of the service users. A new playground had been built in the Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 20 grounds of the home and this included a soft surface in case any of the service users fell on it. All of the service user have their own bedroom which the inspector observed to be decorated to their own tastes and preferences. Their rooms had also been risk assessed to make sure that their room and furniture did not cause any potential problems for the individual service users. The service users rooms are lockable and they are encouraged to lock their doors when they are not in their rooms. The bedrooms also include en-suite facilities, however other toilets are available to the service users close to the communal areas. There are also two communal bathrooms in the home one that includes a shower and toilet and the other included a bath and toilet The home now has better access to the company’s handyman and he works at the home two days a week. This has helped to maintain the environment at the home and makes sure that maintenance that is required does not take too long to be completed. Pictures are on the walls and doors around the environment to prompt the service users to understand where they are and what is in each room. The managements intention is to replace the carpet in the main entrance area of the home with a cleanable floor, the plan was also to replace the carpet in the adjoining communal lounge with a laminate type covering. The inspector stated that the lounge should remain carpeted to ensure the comfort of the service users and uphold a homely atmosphere. The reason that the carpet was going to be changed was that a service user that used this area had previously been incontinent or purposely urinated on the carpet. There was no evidence to support that this was an ongoing problem and therefore there was no identified need or safety reason why the carpet should be replaced with an alternative floor covering. Watermill house does not employ additional domestic staff. The care staff undertake all of the domestic chores in the home, or if it is identified in service users care files as part of their personal development and independent life skill training then they are supported to assist the staff with domestic chores such as cleaning their own bedroom and kitchens areas. The washing machines were programmable to disinfection and sluicing standards. Service users care plans showed that they are supported to complete their own laundry wherever this is possible, safe and is practicable. Watermill House DS0000066605.V346614.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): 31,32,33,34,35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the care staff have all of the necessary knowledge and skills to care for the individual needs of the service users. EVIDENCE: The inspector observed the staff training and personnel files for three of the staff working at the home. These all included clearly defined job descriptions and specifications of the role that they were employed in. Interviews with three members of staff supported the evidence that they understood their own roles and responsibilities and those of their colleagues. All three members of staff confirmed to the inspector that they received all of the training that they required to meet the needs of the service users. Observation of training records and an interview with the manager also supported this information. The home has sufficient staff on duty at all times to care for the service users. The staffing levels are dictated on the dependency rates that individual service Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 22 users have been assessed with. This is above what would be expected through the residential forum. Observations completed by the inspector during the site visit, communications with external professional, interviews with staff and observation of staff training records all supported the evidence that the staff working at the home have all of the necessary skills and knowledge to safely care for the service users that they are responsible for. The staff receive all of the required mandatory training and training in relation to the specialist needs of the service users including challenging behaviours and autism. The staff personnel files seen by the inspector all included the full recruitment procedures for each member of staff. This included the original application form, two references, the interview record and Criminal Reference Bureau (CRB) safety checks. The care staff also confirmed that they do not have any contact with the service users until this process has been completed. Staff interviewed by the inspector sated that they receive regular supervision but commented that this was not always in a formal manner. The staff supervision records did not provide evidence that the minimum recommendation for formal supervision was undertaken by all staff at the home. However there was evidence to show that the frequency and content of formal staff supervision had improved since the last inspection. Watermill House DS0000066605.V346614.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): 37,38,39, 41,42 and 43 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This means that the management of the home understands and supports the needs of the service users and the staff EVIDENCE: The manager of the home was not available on the day of the site visit, however the deputy manager of the home was on duty. The registered manager has completed the registered managers award and NVQ 4 in care. She also has completed a Certificate in Education, City and Guilds 7307 stage 1 and 2 and is up to date with all her mandatory training including 1st aid and moving and handling. Since the last inspection the Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 24 manager of the home has also successfully completed a fit person interview with the Commission. The deputy manager of the home has completed NVQ 2 and 3 in care and NVQ 4 in management. She is also a qualified NVQ assessor. The standard for the management continues to be exceeded. Staff and professionals visitors to the home confirmed to the inspector that the manager has an open door policy and the external managers of the home were also accessible and were very approachable. An effective quality assurance and monitoring system is in position in the home. Surveys are sent out to various different people including service users, families, outside professionals and the homes care staff. Final dates are given for the surveys to be returned and then the results are evaluated and an action plan is developed from the appraisals of the returned forms. All of the records held in the home are stored in accordance with the Data Protection Act 1988 and other good working practice guidelines. All of the recorded information was also signed to identify who had created the entries in the documents. The management of the home ensures that the health, safety and welfare of the service users, care staff and visitors to the home is maintained at all times. This included making sure that gas, fire and electrical systems are well maintained and are serviced up to date. The home also has appropriate insurance in position to cover the buildings and the continuation of the service in the event of a fire. The overall management of the service internal and external ensures the effectiveness, financial viability and accountability of the home. The only difficulty was in the developments for the service that were planned and haven’t yet been completed. This included areas that would improve the quality and variety of the services being made available to the service users. This included the spa area of the home. This was near completion at the time of the last inspection in December 205, however it is still not in uses as it requires an improved water filtration system and no date has been given for this to take place. Internal and external lines of accountability are clear and the management and staff that were interviewed were clear of their own and others responsibilities. Job descriptions and personal specifications were available on all of the care staffs personnel files that were seen by the inspector. This supported the evidence that they are provided with the correct information in relation to their employment and responsibilities at the home. Watermill House DS0000066605.V346614.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 X 2 4 3 4 4 4 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 4 26 4 27 3 28 2 29 3 30 3 STAFFING Standard No Score 31 4 32 2 33 4 34 4 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 N/A 4 3 LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 3 4 4 3 X 3 4 3 Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 26 No Are there any outstanding requirements from the last inspection? 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 YA28 Regulation 23 (1b) 23((2f) Requirement The registered person must reconsider the plans to change the floor covering in the shared lounge. A carpet must be replaced in this area to make sure that a homely atmosphere is provided and is maintained for the service users. Any alternative floor coverings can only be considered after a comprehensive risk assessment has been completed and that it identifies that this would be appropriate and full consultation with the Commission must also be included. The registered person must make sure that all of the staff receive the recommended minimum of six formal supervision periods per year (pro-rata). This will make sure that all of the staff have the necessary skills and knowledge to care for the needs of the service users and will help to identify any further training that they require. Timescale for action 30/08/08 2. YA36 18(2) 30/12/07 Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The registered manager should consider how the daily activities are recorded. For example the smiley faces that are currently used do not really give any indication of how the service users were actually feeling, what provoked their moods and what was or could have been done to reduce any anxieties or challenging behaviours. The registered person should make sure that all of the facilities for the service users are made available to them. This includes the spa area that is currently out of use waiting for a new water filter. Service users records show that when they are feeling anxious the water spa helps them to relax and calm down. The manger should continue with the services commitment to achieving the required minimum of staff to have completed NVQ training. This will help the staff to understand their roles and responsibilities and provide them with the skills to care for the service users. 2. YA24 3. YA32 Watermill House DS0000066605.V346614.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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