Inspection on 20/02/07 for Waters Park House

This inspection was carried out on 20th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Waters Park House 06/01/09

Waters Park House 07/03/06

Waters Park House 11/10/05

Waters Park House 15/12/04

Waters Park House 22/06/04

Waters Park House 22/01/04

Waters Park House 19/06/03

Waters Park House 12/09/02

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

CARE HOME ADULTS 18-65 Waters Park House Exmouth Road Stoke Plymouth Devon PL1 4QQ Lead Inspector Helen Tworkowski Unannounced Inspection 20th February 2007 12.30p Waters Park House DS0000003617.V311098.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 Waters Park House DS0000003617.V311098.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. Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waters Park House Address Exmouth Road Stoke Plymouth Devon PL1 4QQ 01752 567755 01752 562111 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) Waters Park Limited Miss Elizabeth Waters Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23), Physical disability (23) of places Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: Water Park House is owned by Waters Park Limited and managed by Miss Elizabeth Waters. Waters Park House provides intensive rehabilitation support for up to 23 service users who have suffered a brain injury. The home is situated in a pleasant residential area of Stoke, adjacent to the park and within a short distance of Stoke Village. The home provides accommodation 22 units with en suite accommodation; this includes 3 flats, 8 bed sitting rooms and 9 bedrooms. Six units offer self-contained accommodation. Communal areas include a large lounge room, a dining room with a kitchen area and a separate kitchen. In addition to the communal areas, the home offers a number of therapeutic training areas, including a workroom, an art room, a kitchen and a gym/physiotherapy suite. There is level access to all areas of the home and a passenger lift provides access to the first floor. There is a sheltered patio area with seating where service users may smoke if they wish and a small but pleasant garden area. The large staff team includes rehabilitation care staff, occupational therapists, physiotherapists, therapy, education and activity assistants, a workshop co-ordinator, maintenance, catering and domestic staff as well as administrative staff. Waters Park has a Statement of Purpose and Service Users Guide; these documents provide information about what the home can offer. Both of these documents are available in the main office, and provided to prospective service users and their relatives when they visit. The fees for Waters Park are based on an assessment of need, and the home has three bands: high dependency (£1467), medium dependency (£1371), low dependency (£1275). Items not included in the fees include: Chiropody (£10), Hair dressing (£5-£25), Toiletries (£5-£10), Taxis (Approx. £5), holidays (£50£100). Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included a site visit that took place between 12.30pm and 5.30pm on 20th February and 9.30am and 6pm on 21st February 07. As part of this inspection the inspector talked with three service users, and a relative of a service user. The inspector looked around the building and looked at records relating to the care of four service users. The inspector also met with two care staff, a senior staff and an occupational therapist. The Commission received a “pre-inspection questionnaire” completed by the registered provider, which provided information about various aspects of the service. As part of this inspection 17 Service Users surveys were sent out, 3 were returned completed and 4 on behalf of people who had left Waters Park. Twenty-four care worker surveys were sent out, ten were returned completed, 4 were returned on behalf of staff who had left Waters Park. The inspector also contacted four social services care managers, the local district nurse and the diabetic nurse. What the service does well: Waters Park provides a very high standard of accommodation; it is spacious and well adapted to the needs of people with physical disabilities. In addition there is a very good range of facilities to assist in rehabilitation. The home is clean and well maintained. The Service is well staffed with people who have been specifically employed because of their skills to meet the needs of service users including occupational therapists and physiotherapists. Each Service User’s needs are thoroughly assessed before they move to Waters Park and a plan is drawn up to aide their rehabilitation. Service Users are offered a range of activities to aide in this rehabilitation. Service Users needs, including their health care needs are well met, and their privacy is respected and dignity maintained. The home provides an excellent standard of meals, food is well cooked and presented, and service users are consulted about their choice. Where there are specific dietary needs, these are met. Records are up to date and well ordered, and there are systems in place to ensure that standards are maintained. The home is well managed and staff feel well supported and able to seek advice and guidance when they need it. There are good systems in place to ensure that staff are well trained and that there knowledge is kept up to date. Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Waters Park House DS0000003617.V311098.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 Waters Park House DS0000003617.V311098.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): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective Service Users needs are well known before a decision is made about a move to Waters Park House. EVIDENCE: Waters Park has a Service Users Guide and Statement of Purpose; these documents provide prospective Service Users with information about the service they can expect. The Clinical Director told the inspector that these documents were given to prospective Service Users and their families to read when they visit, and are part of the discussions about what is offered by the home. The documents were not looked at in detail, however it was clearly written and presented in a way that would make it easy to read. The Inspector discussed with Clinical Director changes in the regulation that mean that additional there needs to be information in the Service User Guide about the level of fee. Where amendments are made to these documents copies must be sent to the Commission within 28 days. Prior to a person moving to a care home an assessment of their needs must be carried out, this is to ensure that the individual can be assured that their needs can be met. Each person’s file that was looked at had an assessment of need. The Inspector talked with the Occupational Therapist about the process of assessing people, and she confirmed that she was part of a team that made Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 9 the assessments, and that these assessment are made with the service user, their family and professionals providing care and support. Service Users and their representatives also have the opportunity to visit Waters Park House before a move. The Clinical Director also explained that Service Users may be asked to sign an additional agreement which clearly states any expectations or rules that a Service User might be expected to comply with, for example in relation to alcohol. Copies of these documents were seen during the inspection. One of the staff who responded to the survey commented “The admission procedure is excellent, we are all aware as a team of any new clients who are coming to Waters Park, everything is prepared for them, and we tend to their like and dislikes. We always make sure that they have a warm welcome”. The Inspector discussed with the Clinical Director the need for the Registered Provider to confirm in writing to the service user that the service has the ability to meet the persons needs. Waters Park House DS0000003617.V311098.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, and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems in place to ensure that the needs of Service Users are met. EVIDENCE: Three service users were spoken with about what they thought about the service they received at Waters Park. Two individuals were very happy, they talked about how nice the staff were and that they were treated “properly”. One of these people, when asked about who decides things about his/her care said “What I say goes!”. A third person spoken with had very mixed views about the care and assistance received. Each person at Waters Park House has a document that identifies what their needs are, identifies any associated risks and any actions staff are to take. Staff spoken with had read these documents and when asked about care needs of individuals were able to explain what they were. In addition there are documents called “morning programmes”, these provide detailed clear Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 11 guidance to staff about the assistance they are to provide to service user to help them get up in the morning. Review meetings are held every 3 months; Service Users told the Inspector that they attend these meetings. The information about Service Users needs is of a good standard, however the Inspector discussed with Senior Care Staff and the Clinical Director a number of ways that further improvements could be made in the documents that detail the care to be provided: • Service User Plans should be written in a style that allows the individual Service User to be involved and consulted about all aspects of their care, as far as is possible. Information is currently framed in terms of deficits, issues and problems. Whilst it is recognised each person at Waters Park House has these, that it is also important to identity competencies, needs and abilities; and to record a more holistic view of the person. Directions to staff were at times not as precise as they could be. For example in some documents it states staff were to carry out particular tasks on a regular basis, but it was not stated how often this was. Information to care staff (rehabilitation assistants) regarding the care they are to provide in the morning is very detailed and clear. However no such guidance is provided for the rest of the day or night. • • • The Inspector spoke with two care staff about the needs of the Service Users and they had a good understanding of what each person needed. They explained to the Inspector how they were expected to read information about individuals that is on file, and how they were also introduced to individual service users and shown what to do. The Inspector looked at systems for handling Service Users money. There is a good system in place to ensure that money that is held by Waters Park on behalf of Service Users is properly accounted for. The Inspector asked about Service Users having more involvement in handling their money- for example signing, with staff for their money. The Clinical Director said that Service Users are involved in managing their money as part of their preparations to leave Waters Park, and Service Users are not allowed to keep money in their rooms. Service Users should be able to keep their own money safely in their room, unless a risk assessment indicates that this is not appropriate. The Inspector discussed with the Clinical Director and the Registered Manager the Mental Capacity Act that is to come into force in April 2007, and the need for this new legislation to be taken into account in their work. Waters Park House DS0000003617.V311098.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, 15, 16, 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service Users are offered very high standard of meals that are healthy, well cooked, and well presented. There are excellent facilities at Waters Park House for Service Users to use as part of their rehabilitation, with specialist staff to guide individual programmes. EVIDENCE: One of the points consistently raised by Service Users and staff spoken with during this inspection was the high standard of the meals provided. The Inspector spoke with the chef about the meals, he explained how the food was cooked using fresh ingredients, and how he took into account dietary needs. Service Users said that they liked the way that he came and spoke with them about what they thought about the food. One person commented that the food was “excellent.. (the cook)… does a good job”. Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 13 Waters Park has a dining room, though some Service Users have their own kitchen where they may prepare meals as part of their agreed programme. The Clinical Director explained to the Inspector about the standards that staff were expected to meet in relation to meals- for example with regard to laying the table. Service Users also have access to a small kitchen near the lounge so that they are able to make their own drinks between meals. Where Service Users need a soft diet this is provided, the Clinical Director explained that care is also take to make food attractive. Waters Park House has a range of in house facilities that Service Users can use without going out: there is a gym/physiotherapy room, an arts and crafts room, a disabled access kitchen and a quiet room. The Clinical Director explained that Service Users were not just encouraged to use these facilities exclusively but to also use those in the community- for example the local gym. One of the aims of Waters Park is to rehabilitate Service Users; the service employs physiotherapist and occupational therapists to help design rehabilitation programmes. Each person has a timetable of activities, for the week. During the inspection Service Users were seen going out shopping for food to later prepare meals, or to local education facilities. The Inspector asked Service Users what they thought about the activities on offer: one person said that some weeks it was good, other weeks it was not so good. Another person said that he/she had enough to do, they particularly enjoyed trips out to places like Mount Edgecombe. A third person said that they were not satisfied with their timetable. During this visit the Inspector joined a craft group, Service Uses were encouraged to participate in the activity on offer. The Inspector spoke with a relative of a Service User about the service. She explained how Water Park not only cared for her relative but supported her too. She said that she always felt very welcome when ever she visited. Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 14 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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems in place to manage medication. Service Users’ support needs are well met. EVIDENCE: All of the Service Users have single rooms with ensuite shower facilities, so that all personal or health care should be provided in private. There is one separate bathroom, for individuals to use if they would like a bath rather than a shower. Staff were observed knocking on doors before they entered bedrooms, and one of the people spoken with commented that staff always treat her with respect, and that staff always come if he/she rings the bell. The person also commented that staff never moaned about offering help however trivial the request. The three Service Users who responded to the survey said that staff always or usually treat them well, and listen and act on what they say. Staff comments about Waters Park include “…provides a warm friendly environment respecting people’s rights/ individuality/ choices/ needs/ privacy/ Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 15 space. It cares for people in a holistic way”, and “I think they ensure the needs of each individual are fully met, they also listen effectively to the clients and always react in a positive way”. The Inspector spoke with a District Nurse who visits Water Park frequently. She commented that staff call in the Nursing service appropriately, and take the advice offered. She said that staff treated service users with respect and ensure that service users dignity are maintained. Waters Park uses a “monitored dose system”, which is prepared by a pharmacist, for much of the medication. The Inspector discussed with a senior member of staff about how medication was administered, and observed how medication was prepared and administered. Medication is well managed and records are well maintained. Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 16 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems in place to deal with complaints, should they be made, and to protect Service Users from abuse. EVIDENCE: Waters Park has a clear complaints procedure that is part of the Service Users Guide, and it is also displayed on the notice board. The Inspector looked at the record of any complaints made. There was a clear, well-organised system. The Commission has received no complaints with regards to Waters Park House. In the entrance hall, there are cards with addressed envelopes that visitors or service users can use to provide feedback or to comment on the service. All three of the Service Users who completed a survey said that they knew how to make a complaint if they wished to. All ten of the staff responding to the staff survey said that were aware of the adult protection procedures. The Clinical Director told the Inspector all staff were sent, at the first opportunity, on the Social Services course on the protection of vulnerable adults. Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 17 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 excellent. This judgement has been made using available evidence including a visit to this service. Waters Park House provides spacious, clean, comfortable and well-adapted accommodation for people with a range of disabilities. EVIDENCE: Waters Park House offers people a range of accommodation- from bedrooms with en-suite facilities, to bed sitting rooms with ensuite facilities to large and spacious flats. All of the 22 accommodation units exceed the 12 sq. m of useable space, set in the national minimum standards. Not all of the rooms were seen, however those that were seen were well decorated and well maintained. Service Users had brought items of their own furniture or equipment. Each of the rooms has an ensuite shower facility, with all but one being a walk in shower. In addition there is a bathroom with a hoist. There is level access throughout the building and there is a passenger lift to the first floor. Waters park has a large communal lounge and dining room. There is also a small kitchen area near the lounge so that Service Users are able to make their Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 18 own teas and coffees. In addition there is a gym/ phsyio room, an arts and crafts room, a quiet/counselling room, and a disabled access kitchen. These facilities are used with staff as part of rehabilitation programmes. There is ample space for staff, administration and for meetings. This care home is well adapted to meet the needs of people who have disabilities and who are being rehabilitated. The fact that all of the individuals have ample private space means that there the service users can opt in and out of “communal life”, and this may help lessen potential conflicts between individuals. One service users spoke with the inspector about the accommodation provided, saying that she felt her accommodation was very spacious and was pleased with the refurbishment of the room. There were no offensive odours, the home has a well-equipped laundry and domestic staff are employed to help maintain the high standards in this home. There was evidence of good hygiene or control of infection practices. Gloves and aprons were being used appropriately, and staff were aware of what was expected of them. The three service users who responded to the survey said that Waters Park was always or usually fresh and clean. Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 19 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): 32, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service Users are well supported by competent and well-trained staff, who are present in sufficient numbers. The records of staff recruitment indicate these procedures are not robust, though staff are well supervised and supported whilst working. EVIDENCE: All ten of the staff who responded to the staff survey said that they were never asked to care for people outside their area of expertise and that they felt that they were well supported to do their jobs. Comments made by staff include: “Waters Park House is a supportive and stimulating environment to work in… it is a good breath of fresh air to feel valued and appreciated”, and “I thoroughly enjoy working at Waters Park House. I have gained a lot of knowledge and experience”. The Inspector looked at the recruitment records for three staff who had recently started work in the home. As part of the recruitment process care homes are required to ensure that they take a full employment history, two written references and make checks as to whether the individual has a criminal Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 20 records bureau check or should not work with vulnerable adults. Whilst there were records to indicate interviews had taken place, written references were not on file or had been received after the start of employment. For one person employed by Waters Park House Ltd there were no proper recruitment records as the recruitment had been managed through an agency before employment. When a care home employs a person then the proper recruitment checks must be made. When an individual is employed by an agency to work in a care home then there the home must have verified that the agency has carried out the appropriate checks. The Inspector provided the Clinical Director with the Commissions guidance on recruitment including Criminal Records Bureau Checks and Protection of Vulnerable Adults checks. There were good records of training; these showed that staff received induction and other training to enable them to do their job safely. One new member of staff was observed during the inspection shadowing a more experienced staff member. There were records on file to show that where staff had not completed training within agreed timescales this matter was followed up. The home has it’s own internal training programme- including “snap shot training”. This training last half an hour each week and focuses on a particular subject such as: strokes, lobes of the brain, the role of the physiotherapist. In addition there was evidence to show that staff had received more in depth training including in relation to epilepsy, and motivational techniques. The inspector spoke with two care staff about their role and they both commented that they felt well supported and were able to seek advice or support if they were ever unsure. The rota was seen during this inspection, there were sufficient care staff to meet the needs of service users and the rota had been changed as the needs of service users changed; in addition there was support from occupational therapists, and from physiotherapists. A full time cook is employed and there are domestic staff. Staff told the inspector there was sufficient time to not only carry out care tasks but to spend time with Service Users. Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 21 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, 39, and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the service is good, and ensures that a good standard of care is consistently delivered to meet the service users’ needs. EVIDENCE: Ms Elizabeth Waters is the Registered Manager at Waters Park House. She has many years experience of running care homes, and has the appropriate qualifications. In addition to Ms Waters, a Clinical Director is employed who Over see much of the day-to-day operation in the home. The care home is well organised, records are well ordered and up to date, and staff know what they are doing. These all indicate a well-managed service. There is a good quality assurance system that is based on seeking the views of Service Users. These views feed into an annual development plan. Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 22 It was noted at the last inspection that that under Regulation 26 of the Care Home Regulations a representative of the company should visit the unit each month (unannounced) and check the running of the service. A report of these visits should be forwarded to the Commission. The Commission has received no reports of these visits. As part of this inspection the Inspector looked at risk assessments, which should help ensure that service users and others are not exposed to unnecessary risks. There is a fire risk assessment, and checks are made of the fire system, and staff receive regular training. However the risk assessment was not as specific as it should have been – for example specifying how frequently staff needed to receive training. There were checks made on the water system to ensure that hot water was at the correct temperature, however there was no actual Legionella risk assessment. The home is well maintained and where concerns had been identified- for example in relation to security- these had been addressed. Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 23 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 x 4 X 5 X 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 3 25 4 26 3 27 4 28 4 29 4 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 1 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 4 12 4 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 3 X 4 x 3 X X 3 X Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Waters Park House DS0000003617.V311098.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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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