Inspection on 25/02/08 for Waterloo House

This inspection was carried out on 25th February 2008.

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

Waterloo House 18/08/08

Waterloo House 14/09/06

Waterloo House 14/06/06

Waterloo House 10/08/05

Waterloo House 02/06/05

Waterloo House 11/08/04

Waterloo House 04/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Waterloo House Waterloo Road Bidford On Avon Warwickshire B50 4JH Lead Inspector Yvette Delaney Key Unannounced Inspection 25th February 2008 09:00 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 Waterloo House DS0000004260.V358609.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 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. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waterloo House Address Waterloo Road Bidford On Avon Warwickshire B50 4JH 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) 01789 773359 01789 774791 www.alphacarehomes.com Alpha Health Care Limited Mrs Maria Cosgrove Care Home 35 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (20), of places Physical disability (1) Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 2006 Brief Description of the Service: Waterloo House is situated within walking distance of Bidford Upon Avon where there are shops, churches and a bus service to Stratford Upon Avon. The home is registered to provide personal care for up to 35 older people. The home is divided into two buildings. The main house is a large Victorian house, which has been converted to accommodate up to 21 older people requiring personal care. Bedrooms are available on the ground and first floor of the home. All have en suite facilities. The first floor is accessible via a chair lift only. The other part of the home is called ‘Avon Lodge’. This is a purpose built premises located separate to and behind the main house. The house can accommodate up to 14 people with dementia. This building has 14 individual bedrooms with en suite facilities. There is a passenger lift to the first floor as well as stairs. Current fees for this home range from between £440 to £505 per week. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this home is a no star rating. This means that the overall outcomes for residents in this home are poor, based on the information gained during the inspection process. The focus of inspections undertaken by us is upon outcomes for the residents and their views of the service provided. This process considers the capacity of the service to meet the regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. This was a key unannounced inspection visit, which addresses the essential aspects of operating a care home. This type of inspection seeks to establish evidence showing continued safety and positive outcomes for residents (people living in the home). This key inspection visit showed that the home has made some improvement. There remains however, the need for further improvements if the home is to meet regulations and national minimum standards recommending good practice. The Pharmacist inspector carried out a separate inspection visit to the home on 21 December 2007. The inspection outcome showed that the management of medicines in the main house of the home is poor and practice at that time would not protect residents from the risk of harm. The Pharmacist’s findings have been included in this report. Before the inspection the previous registered manager for the home was asked to complete an Annual Quality Assurance Assessment (AQAA) detailing information about the services, care and management of the home. Following receipt of the AQAA, a number of questionnaires were sent out to people who live in the home and their families to ask their views about the home. Eight questionnaires were returned from family members. Information contained within the AQAA and questionnaires is detailed in this report where appropriate. Three people living in the home were identified for close examination by reading their care plans, risk assessment, daily records and other relevant information. This is part of a process known as case tracking and where Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 6 evidence of the care provided is matched to outcomes for the residents. It was difficult to have meaningful conversations with the residents due to their poor mental health. Therefore, individual outcomes for some residents are also supported by observation and talking to relatives. Other records examined during this inspection, include staff recruitment records, training records, social activity records, staff duty rotas, health and safety records and medication records. An ‘expert by experience’ accompanied the inspector on part of this visit. This is someone who has experience of care services themselves, due to having a member of their family in a care home. This person is actively involved with ‘Help the Aged’ and sits on a relative’s forum for an elderly person’s care home. The expert by experience takes the opportunity on the inspection visit to talk to residents, visiting families and staff. Findings in this report are also based on the persons’ observation of the interaction between people who live in the home and staff. Their findings are also included in this report and used as evidence when deciding on the quality of service provided at the home. What the service does well: Comments from relatives spoken with and through questionnaires received include: “The staff are caring and kind and take very good care of the physical needs of the residents. The atmosphere in the home is generally happy and welcoming. I am always made welcome.” “We are very satisfied with the Home”. “There seems to be a small turnover of staff here which is a good thing”. “Residents are treated with respect and dealt with individually and I have seen no abuse during my visits”. “There is a good atmosphere here”. “In general I think that they do a good job…very rarely have I had to complain about anything…. I am very grateful for all they do.” “Waterloo House cares for my… (Resident) in a calm and caring way.” Pre-admission assessments read provided details of the health and personal care needs of all the three people. The availability of this information ensures that the specific care needs of each person are identified and can be used to complete a plan of care. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 7 A member of staff undertakes activities in both parts of the home, five days a week. One session in the mornings and a further session in the afternoon, this gives people living in both houses, which make up the home the opportunity to take part in an activity. A good programme of activity is evident. This will keep residents both physically and mentally stimulated. What has improved since the last inspection? What they could do better: An up to date Statement of Purpose and Service User Guide should be available in the home. These documents should be available in different formats suitable to the meet the needs of people who use the service. This will ensure that people who use the service have current information, which helps them to make informed decisions about the home. Care plans developed in the home need to be audited to ensure that they are appropriately completed, clearly identify resident’s care needs and contain up to date information about the needs of people living in the home. Due care must be taken to ensure that resident’s are supported to meet the personal hygiene needs so that they are clean and suitably dressed to meet their needs at all times and appropriate for the time of year. The management of medication in the main house must improve if people living in the home are to be protected from the risk of harm. Ensure that equipment used in the home has ongoing maintenance and is serviced to assess its suitability for use. This will ensure that residents are protected from the risk of harm. Staffing levels should be reviewed to ensure that sufficient numbers are on duty at all times. Attention should be given to peak times of activity in the home, which includes mealtimes and where two members of staff are required Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 8 to meet residents’ care needs using appropriate and safe practice. This will ensure that residents care needs can be met safely at all times. A review of the concerns highlighted about the communication problems and language barrier between the elderly people living in the home and staff should be reviewed to ensure that this is not having an adverse affect on the health and wellbeing of the elderly people living in the home. Recruitment practices in the home must improve to ensure that they are robust enough to protect the vulnerable people living in the home from the risk of harm. Access to areas of the home, must be reviewed to ensure that people living in the home are able to occupy rooms provided for their use, safely. This includes the conservatory, en-suites, toilets, and bathrooms. A review of the uneven floor in the corridors of the main home must be carried out. This could present a trip hazard for residents; particularly considering those who don’t want to remain seated and are constantly walking around the home. 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. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 9 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 Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is adequate. People who are considering moving into the home do not have up to date written information available to fully support them in making a decision about the home. People have their care needs assessed before moving into the home so that they can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: An up to date Statement of Purpose and Service User Guide are not yet available for the home. The Regional Manager advised that the documents would be available in different formats for example DVD and large print by the middle of March. However, relatives of residents spoken with said that they were well informed when making the choice for moving into Waterloo House. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 11 One family member confirmed with the expert by experience that they were well informed when choosing a Home for their relative. An assessment was carried out at the resident’s home before coming to Waterloo House. Relatives are aware they are able to visit at any reasonable time. The family member spoken with was aware of the procedures of the Home and had inspected the Home’s current Statement of Purpose and Service User Guide. They were also made aware that they could be involved in planning their care. Relative’s comments include: The care files of three residents of the most recently admitted to the home were reviewed through the case tracking process. The pre-admission information for all of these residents was examined. Assessments read provided details of the health and personal care needs of all the three people. Information available includes mobility, history of falls and their medical history. The availability of this information ensures that the specific care needs of each person are identified and used to complete a plan of care. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. Care plans show improvement and provide staff with some guidance on aspects of resident’s needs this should result in appropriate care being given to residents. Medicine management is good on the EMI unit this does not protect the wellbeing of people who live in the home. Residents are treated with respect, which helps them to maintain their dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We identified three residents who could be followed through the case tracking process. The care plans for these residents were examined. Residents identified had varying degrees of confusion or had been diagnosed with dementia. It was not easy to communicate with residents, due to their mental health state. Observations, examination of resident’s files and talking to care staff and family help to case track the care received by these residents. All the residents required support with personal care. It was identified at the last Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 13 inspection that care plans needed to improve to ensure that they clearly identified each resident’s care needs. Talking to the staff and examination of care files demonstrates that some care files had been appropriately reviewed and care plans updated to identify current care needs. Care plans have been developed so that care staff identify the residents care need, say what they aim to achieve with or for the resident. A plan of action is then written to show what staff need to do to support the resident in meeting their care needs. Some care plans failed to identify a specific care need or problem for individual residents. These plans detailed information on the action staff had to take to provide care for the resident, but failed to show what the persons assessed need was. Staff would not know if the prescribed actions they were instructed to take were appropriate for individual residents. There were examples were improvements in the writing of care plans had improved one example of this was a care plan written to meet the oral hygiene needs of a resident. Information read in one care plan identified that a resident: “…needs assistance from one carer to keep… (Resident) teeth clean due to…confusion.” Action detailed in the ‘Plan of Care’ to be taken by staff includes: “Ensure… (Resident) has the correct equipment to clean... (Resident) teeth – toothpaste, toothbrush.” “Remind and prompt… (Resident) to clean...teeth.” “Ensure that a dentist visits to check… (Resident) teeth regularly, every 6-12 months.” Care plans however, were inconsistent in the level of information they contained. Examples of were: Details in a care plan written for a resident needing a high fibre soft diet and was showing signs of weight loss. The care plan did not mention any suitable nutritious foods that would be suitable to be served as a soft meal and based on the residents’ likes and dislikes. Although there had been significant weight loss, staff were instructed to weigh this person monthly. This frequency may not be sufficient to monitor the resident’s wellbeing and act on any concerns quickly. There was no evidence that a referral was made to a dietician or the resident’s doctor. Food charts were not introduced to monitor the person’s food intake. The resident’s weight had been recorded but not always monthly as requested. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 14 However, a further care plan completed for another resident experiencing weight loss contained a bit more detail covering action to be taken such as: “Please weigh… (Resident) weekly.” “Offer fortified drinks” (This could be drinks made with full fat milk, cream added to some meals, such as porridge or supplement drinks which helps to increase the nutritional value of foods eaten by the residents) “Notify GP if weight falls below… Risk assessments were comprehensive and these had been completed in all care plans examined. These include risks related to pressure areas, falls, mobility and nutrition. This gives staff information they need to provide and meet the specific and current care needs of people living in the home. Information available in care plans identified that one of the residents had been assessed as being at risk from falling out of bed. The outcome of the risk assessment showed that the person needed bedrails to maintain their safety. Risk assessments had been reviewed; one care plan showed that a resident had been re-assessed due to continued falls to determine whether they needed support when walking. Written entries in resident’s care files were not always dated, timed and signed with the person’s signature. This will ensure that a legible and effective audit trial is available to track the care given to people living in the home. A family member reported that care plans were reviewed on a monthly basis with them and their relative. Families also said that they were kept informed of any incident that affects their relative. “The staff always tell me if my… (Resident) falls/faints or is unwell.” Entries in the resident health records and comments by people living in the home confirmed that they are supported in getting access to relevant health care professionals when needed. This includes access to GP, Chiropodist, Community Psychiatric Nurse and Optician. Although there was some evidence that residents were able to access the services of a Dentist, one family member commented “It is a bit late for my… (Resident) now, but I wish that there had been some sort of dental care offered at the home…” The reason for this pharmacist inspection was to inspect the medicine management within the home. Eight resident’s medicines were looked at together with their medicine charts and some care plans. The outcome is as follows: The medicine management in the residential unit was poor. The medicine management in the EMI unit was good. All requirements left following the inspection are a result from the poor practice seen in the residential unit. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 15 The system to check the prescriptions before they were dispensed was poor and this resulted in some medicines not being prescribed in time so service users went without prescribed medicines. Staff failed to recognise this until the medicines had been dispensed and delivered to the home and even then one medicine was found to be out of date and had not been re-ordered to be replaced. This is of serious concern Many medicines had been recorded as administered when they had not been. Two inhalers had been recorded as administered but both were still in the sealed box so had not been. Records did not reflect actual practice in some instances. Some medicines had been recorded as refused but they were not actually in the medication trolley taken to the residents to offer, but kept in the surplus cabinet used to store the trolley. Some gaps were seen on the medicine charts. Some had been administered but not recorded, but others had not been administered and the reasons for none administration not recorded and some it could not be demonstrated exactly what had occurred. Medicines were found that were out of date. This is of serious concern as one was an eye drop. This had not been re-ordered so staff were using the bottle opened the previous month. This would increase the risk of an eye infection as eye drops only have a 28-day expiry due to increased risk of microbial contamination if used after this time. The majority of medicines were dispensed in a monitored dosage system. These had been given correctly and recorded as such but some had exceeded their expiry date of eight weeks in these packs. This may affect their stability and could cause potential harm to the residents if administered. Some medicines were found in the trolley that had not been recorded on the medicine chart. It could not be demonstrated when these had been given or whether they were still to be given as the care plans failed to support their use. Concerns were raised when some medicines had been prescribed for a short course of a month but were still available to administer five months later. These had not been administered as the doctor intended. Care plans failed to record all the doctor’s visits and communication so it could not be demonstrated why some medicines had been prescribed in the first place. No protocols were seen to support the administration of medicines prescribed on a “when required” basis. The care plans failed to fully support the resident’s clinical needs. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 16 Three loose tablets were found in the trolley. It could not be demonstrated what one was or who they had been prescribed to and why they had not been administered and not destroyed. Some old creams to treat an infection were also found in the trolley. One resident had refused the application. Staff had failed to report this to the doctor for him to reassess the clinical condition. A quality assurance system had not been installed to check individual staff practices. This was a requirement from the last inspection. The home had insufficient storage facilities for medicines. The medication trolley for the residential side was too small to house all the medicines dispensed. This resulted in medicines being kept in the walk in cupboards, so not actually available to offer without a trip back to the cupboard. This may explain the constant records of refusal for these medicines. Concern was raised why they were repeatedly prescribed if not actually administered as staff had failed to discuss this with the doctor. Two trolleys for the residential unit were recommended so all the resident’s medicines can be taken to them to offer. The walk in medicine cupboards had no internal locked cupboards so if the cupboard was left open everyone had access to the medicines stored within. The home had no Controlled Drug cabinet as required now by the Misuse of Drugs (safe custody) Regulations 1973 as amended. The medicine management on the EMI unit was good. The deputy manager undertook the role of overseeing the whole process. Systems were organised and well run. This was commended. All feedback following the pharmacist inspection was given to the deputy manager, acting manager and operations manager. They were all very proactive and were keen to correct the errors seen and identified positive ways for meeting the statutory requirements not met during the inspection. Residents were not all appropriately dressed at the time of the inspection. The clothes of one resident sitting in the lounge were undone. The manager advised that the resident often undressed themselves; nothing was recorded in the care plan about this. There were no instructions for staff on how to manage this behaviour. A comment received from a relative said that, “Occasionally my… (Resident) appears unclean and inappropriately dressed.” Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 an 15 Quality in this outcome area is adequate. Open visiting arrangements encourage regular contact with relatives and friends. Varied social and recreational activities meet the needs of all residents. Staff are not fully aware of how to manage mealtimes for residents who cannot sit for long periods. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The expert by experience spoke with staff, residents where possible and relatives about day to day life in the home and reported the following: A member of staff undertakes activities in both parts of the home, five days a week. One session in the mornings and a further session in the afternoon, this is to ensure that both houses, which make up the home, have the opportunity to take part in an activity. A good programme of activity is evident. An activity (seated) was observed in the House, this was organised by the activities coordinator and started at about 2.45pm after an activity had taken Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 18 place in the other part of the home, Avon Lodge. The activity ‘movement to music’ took place with the aid of one care worker. Residents were offered water while undertaking the activity. Good interaction was observed between staff and residents, observation of staff showed that they were supportive and caring towards residents. There is a “reminiscence wall” in the home this was comprehensive and too much information was on the board. This could be too confusing and over stimulating for the residents as there would be too much detail for them to concentrate on and take in. Work is being carried to imitate a street environment. Letterboxes have been attached to resident’s bedroom doors and a “bus stop” and “train station area” have been located in the corridor of the home. Relatives spoken with felt that the home offers a good range of social activities. However, a relative commenting said that they were concerned that so much money had been spent on …”Dummy letter boxes and door knockers...” and expressed that the money could have been spent in more needy areas such as the hire of a mini bus to take residents out for an afternoon. The relative goes on to say: “The idea that such things give old people in such circumstances a feeling that it is their own home is nonsense.” Research has shown examples of good and clear design when planning a suitable environment to support people with dementia. This includes ensuring a familiar, domestic and homely style and providing age appropriate furniture and fittings. Information shared with us by the home said that meetings were held with family members and other representatives to explain the changes to the environment. There is a “Relative’s Forum” for input from/on behalf of residents to feedback joint concerns (or positive comments) to the management. A list of monthly meetings was seen in the dining room to which all residents and relatives are invited. It is not evident reading the comments above from a relative that changes in the home have been fully discussed. A further relative said that relatives need more information about the home. The relative commented that they had tried several times to start a ‘Newsletter’ for the home with dates of events to be posted out to families but the information is not always available or passed on to them. The Home has no transport of its own but takes a few residents out at a time, walking or into the shopping area in a hired vehicle. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 19 Residents order lunch the day before and menus were on display in the dining room. There is a choice of two mains and two puddings. Some residents spoken to could not remember what they had ordered, this could be due to resident’s level of confusion due to their mental health and many of the residents have a diagnosis of dementia. This practice could only lead to further increase resident’s state of confusion and deterioration in their wellbeing. Both the expert by experience and the inspector had lunch with the residents. One had lunch with the residents in the main house and the other in Avon Lodge. Both felt the meals were appetising and well presented. The expert by experience commented: “Two courses were served between 12.15 and 1.30pm. I ordered a chicken curry and ice cream. My meal was served hot and was tasty. The expert by experience observed that care and patience was given to residents by three carers in the dining room. Residents ate at tables in the dining room and one resident was being fed in the conservatory. The residents, I was sharing a table with, seemed to enjoy the food although they did not eat their entire main course. A resident at my table had a coughing fit while eating and was attended to sensitively, although to begin with no care staff member was in the dining room. It was evident that three care workers were not coping entirely with helping to serve and feed 14 residents in the dining room. Comments by residents at lunchtime were: “The food is Ok but it could be better” and “I like it here”.” “My mother tells me that the food is good”. The weekly menu was visible on a notice board and seemed varied. There is a four weekly cycle of menus. Tea is served daily at 2pm and 4pm with biscuits and/or cake. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. People using the service cannot be sure that their concerns will be fully investigated. This could lead to a lack of confidence in the home. The adult protection procedure and staff awareness of the procedures reduces the risk of abuse. This practise will help to ensure that people living in the home are protected from harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Relatives spoken with said that they are aware of the complaints procedure and would complain if necessary. The complaints procedure is displayed in the reception area of the home and copies are available in the Service User Guide. Comments made include: “There are details on how to complain on the notice boards and of course you can always talk things over with the manager.” “We are able to discuss any concerns with... (Resident) named carer or as well as the manager.” “I have never had cause to complain.” Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 21 A number of complaints had been received by the home. The concerns raised in these complaints relate to; care, personal hygiene, missing clothes, bedding not warm, wearing same clothes and room not clean. Eighteen formal complaints both verbal and in writing had been received by the home. Records examined confirmed that the complaints had been acknowledged and investigations carried out. The response to one complaint was read, the letter did not clearly explain the outcome of the investigation or acknowledge if any aspect of the complaint had been upheld. Failure to write a full response, following the investigation of a complaint will not ensure that complainants feel confident that their complaints will be fully investigated. The policy and procedure detailing the action to be taken by staff to ensure the protection of vulnerable adults were examined. The information guides staff on the procedures to follow if they saw or suspected evidence of abuse. Staff were able to confirm that they had attended training related to the protection of vulnerable adults. Two members of staff were able to explain the action they would take if they saw abuse. Both answered appropriately. There have not been any incidents referred to the adult protection team for further investigation. The expert by experience said that he saw no evidence of abuse, verbal or otherwise on the day of inspection. Care and consideration by members of staff towards residents was evident at all times. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26 Quality in this outcome area is adequate. The environment is varied throughout the home in relation to safety, comfort and hygiene, which might reduce the experience of quality of life for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Waterloo House Care Home comprises of two buildings, the main house known as, ‘Waterloo House’ and Avon Lodge. Avon Lodge is only accessible by a separate entrance to the main house. The main building is a Victorian house with extensions built on the back. The Lodge is a purpose built unit on two floors at the rear of Waterloo House. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 23 A number of the views expressed below are as seen through the eyes of the expert by experience the outcomes were observed by the manager for the home and us. We noted the following: New or recently replaced carpets were observed in most areas although some still require replacing. The corridors and dining room had “cushion flooring” which seemed to be the non-slip type. This should offer as soft a surface as carpeting. Walking around the home the flooring felt hard and concern was raised about injury that may be caused if residents were to fall. The manager produced data after the inspection to show that the flooring is cushion flooring. The flooring in the corridor of the home was noted to be uneven, which could present a slip hazard for residents. During the tour of the home evidence of odours was noted from one room in the home only and nowhere else. The furniture in the common areas was functional and appropriate. Three residents were sitting in a conservatory situated off the dining room at the front of the home. The access is to the conservatory was discussed with staff and the manager as residents would have to negotiate a step up from the dining room. This could present a trip hazard to residents at risk of falling. Bedrooms on the first floor of the home are accessible by stairs or a stair lift. Residents who find it difficult to use the stairs are supported to use the stair lift. A shared bedroom situated on the first floor of the home is used by one of the residents followed through the case tracking process. Two people who are not related share the bedroom. The room offers a large space but the layout did not clearly define two living spaces to ensure privacy. The resident included in the case tracking process slept on a hospital type bed. Closer examination evidenced that the bed was not working and the state of the mattress would not allow the resident to have a comfortable night sleep. There was a dip in the mattress, leaving the mattress curved and the head of the bed and the bed itself could not be lowered. The extractor fan in the ensuite of this room was not working, as the wiring had not been completed. This may affect the comfort of anyone using the en-suite. There are three bedrooms on the first floor all have access to one bathroom, which had suitable equipment. However, the residents in one of the bedrooms on this floor would have to negotiate down two steps to gain access. This would be difficult for residents with mobility problems. Further single bedrooms were inspected on the ground floor and these had ensuites, some with toilets only and others with shower baths, which again were not suitable for the residents living in the home, as they would need to climb into them. The en-suites were also quite small so providing very little room for manoeuvre. A number of the extractor fans in the en-suites were dirty and Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 24 clogged with dust. One of the toilets on the ground floor had an unsuitable toilet seat for use by residents and the light pull had a large screw exposed, making this unsafe for use. Some of the bedrooms are personalised and residents are able to bring in their own possessions and items of furniture if desired. Some of the bedrooms visited were clean and tidy and the “house” furniture was reasonable. The main lounge in the main house was at the front of the building and this seemed small for the number of residents, although some could use the conservatory, which had some chairs in it. There was one television and audio equipment in the lounge. The dining room had suitable tables and chairs and some “snoozalem” equipment was being stored in it in advance of being installed in Avon Lodge. All the common areas were pleasantly decorated, although with some evidence of wear and tear. The kitchen is off the main corridor. There did not seem to be enough work surfaces and it was not appropriately set out to allow the kitchen staff to work easily. There is a well-organised food store (larder), two freezers and one fridge. Plated food was covered and opened food containers were sealed and date marked. However, outside the back door to the kitchen, an unlocked metal locker contained all the fresh daily delivered vegetable supplies. These were observed still in the locker after the cook had left for the day. The laundry, situated in Avon Lodge was visited. The laundry was untidy, disorganised and laundry was building up. Laundry staff are not employed daily and therefore the expectation is that care staff will do the laundry. This is concerning as it was evident that there would not be sufficient staff on duty to meet the care needs of residents and undertake other domestic duties. A relative commented about the laundry: “Up until recently my… (Resident) was quite concerned about how other people’s clothing was getting into her wardrobe…now (Resident) doesn’t notice, but I think more care should be taken where the laundry is concerned.” There is minimal parking available at the front of the home. Access to the front entrance of the home is by a ramp. The access is narrow and this is further made difficult by a tall hedge on one side, which could difficulty for residents especially if they have to negotiate the entrance in a wheelchair. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. The allocation of staff on duty does not allow for ongoing observation of residents during peak times of activity. This could expose to residents to the risk of harm. The majority of staff are qualified and have attended Mandatory and other training related to the needs of people in their care. This will ensure that competent staff care for people living in the home. Staff recruitment procedures are not robust and consistent to ensure residents are protected from the risk of harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection the manager, the deputy manager and five care staff provided cover for both parts of the home. Three care staff were working in the ‘House’ and two care staff with the deputy manager were working in the ‘Lodge.’ There was also a cook and kitchen assistant working in the home. Staff are available from Tuesday to Saturday to work in the laundry. Four consecutive weeks duty rota shows that a total of 30 hours per week was worked by a member of the laundry staff. Two cleaners are employed they work a total of 54 hours per week. One cleaner is available on Friday each Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 26 week with no cleaners available at weekends. Bank staff are available to cover laundry and domestic duties when domestic and laundry staff are on holidays. The manager provides on-call cover for the home and an area manager would be available for support. It was evident that there was not sufficient staff on duty at all times of the day. For example this was seen at mealtimes when there was not enough staff to help people eat their meals. There were a number of concerns expressed by relatives about the number of staff from overseas working in the home. The concerns raised were mainly about the communication problems the language barrier caused for the elderly, who already had difficulty communicating due to their mental health resulting in confusion and dementia. “Care staff that are not of English origin should speak English at all times.” “Engagement of overseas…labour can cause language problems.” “Occasionally I have felt that staff do not understand… (Resident) requirements. On the whole staff are very good.” “The staff are very caring but due to the number of staff coming from other countries I am not sure they can make themselves clear to residents.” The mental health and wellbeing of the elderly people living in Waterloo House who are already experiencing difficulties with communication and interaction with people could deteriorate, due to their inability to understand some of the carers who have foreign accents and dialects to their English. Three staff files were examined information available did not confirm that all staff had received an appropriate induction, which is linked to the common induction standards developed by the Skills for Care Council. One staff file contained evidence that the member staff had received an induction period. Training records showed that staff had received some training. The home is working towards providing a service for residents who have been diagnosed with dementia. The manager and area manager advised that plans are to provide training for all staff related to the care of people with dementia and all staff would be completing a programme of training titled ‘Yesterday, Today, Tomorrow’. Staff files and information received from staff working in the home confirmed that they had attended some training. Topics covered include: Dementia Awareness, falls and basic food hygiene. Ensuring that staff receive training appropriate to the care of people living in the home will support residents receiving care appropriate to their needs and promote their wellbeing. Further examination of the staff files did not confirm that robust recruitment practices are consistently followed. An application form was seen in one file Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 27 and none in the other two files. Two files contained one reference from a previous employer and a character reference although there was some evidence of previous employment. The remaining staff file although containing references from previous employers, the last employer for this person had not been approached. The Regional Manager for the home provided information after the inspection to explain that the reference was from the last employer. The wrong form had been used to obtain the reference. The outcome for Criminal Records Bureau (CRB) checks had been received for two members of staff. The third had been requested. This member of staff was working in the home with a mentor awaiting the outcome of a CRB check. A check of the Protection of Vulnerable Adults register had been carried out and the outcome received before the member of staff started working in the home. The introduction of robust recruitment practices will support the safety of people living in the home. Training records were available on file to demonstrate training attended by staff. These showed the three members of staff had completed some training in 2007/08. The home is working towards providing a service for residents who have been diagnosed with dementia. The manager and area manager advised that plans are to provide training for all staff related to the care of people with dementia and all staff would be completing a programme of training titled ‘Yesterday, Today, Tomorrow’. Staff files and information received from staff working in the home confirmed that they had attended some training. Topics covered include: Dementia Awareness, falls and basic food hygiene. Ensuring that staff receive training appropriate to the care of people living in the home will support residents receiving care appropriate to their needs and promote their wellbeing. “A wide range of nationalities are employed at the home to care for the residents. Most speak excellent English but not all. It is difficult for elderly people … to understand some of the carers who have foreign intonations to their English…” There were two male care assistants working in the home one in each of the buildings. This practice will help to support male residents living in the home and give a choice of carer to meet their needs. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 28 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 and 38 Quality in this outcome area is adequate. Shortfalls in the monitoring of services provided and health and safety management does not promote residents’ safety and wellbeing. Residents’ benefit from having their needs met by staff who are supervised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The recently appointed manager for the home and the Regional Manager were present at this inspection. The manager is knowledgeable about people in the home this includes residents and their families and staff. She is responsible for the care practices in the home and the overall day-to-day management of the Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 29 care home. The manager has worked in another home as a deputy manager but has not yet acquired the necessary experience to run the care home. She has completed a National Vocational Qualification (NVQ) level 4 in care management and is currently doing the Registered Manager Award (RMA). Support for the manager is available through the area manager. Conversations with the manager during this inspection show that she is keen to make improvements in the home. The organisation has implemented a quality assurance system. Both the manager and Regional Manager confirmed that they had started quality audits starting with resident’s bedrooms, housekeeping, and standards of care, infection control and the kitchen. This will support the manager to monitor the quality of services provided to people who live in the home. The Regional Manager carry’s out monthly unannounced visits to the home to look at the service provided and obtain residents, relatives and staff views on the running of the home. The outcomes of these visits are formally shared with us by sending monthly reports to our office. The reports received have been informative at times. The information provided gives some details on how well the service is doing as well as action to be taken to improve practice and the environment. Staff supervision takes place in the home. Supervision of staff is mainly carried out in group sessions or during meetings, this is not good practice and does not allow for observation of care practices, delivery of personal care and training. The newly appointed manager for the home said that future plans are to carry out supervisions on a one to one basis for individual staff. The home informs us of any incident or event that affects the well being of people living in the home. Responses received in questionnaires confirmed that relatives are informed of important issues affecting residents. Health and safety and maintenance checks had been carried out to ensure equipment in use is safe and in full working order. Records had been organised and were available in on place. Electrical equipment used in the home had been tested to ensure us it was safe to use and appropriately wired. The ‘5’ year electrical certificate was available and current. Water temperatures checks had been recorded monthly and this assists in the prevention of people accidentally scolding themselves. Maintenance checks were completed on fire systems and equipment. Records related to maintenance and services related to the environment were organised. A number of areas of concern related to health and safety have been highlighted in this report. One of these is the access to the conservatory were residents have to negotiate a step up from the dining room. A resident was sitting in the conservatory in a mobile armchair. Staff were asked how they managed to transfer the resident into the conservatory. It was explained that Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 30 the chair would be tilted backwards and manoeuvred into the conservatory. This practice puts the resident at risk from harm and is a health and safety risk to residents. Although it was not a hot day the conservatory seemed too hot, which would make it uncomfortable for residents to sit for a long period. Another is the uneven floor in the corridors of the main home. The flooring has just been laid in the corridors. This could present a trip hazard for residents; particularly considering those who don’t want to remain seated and are constantly walking around the home. Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 31 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 2 2 2 X 3 X 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X 3 X 2 Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 32 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 OP7 Regulation 15 Requirement Timescale for action 30/06/08 2 OP7 15 3 OP8 13 4 OP8 12 Care plans must provide staff with information on how to meet the care needs of people living in the home. This will ensure that people have their needs met. The care files and plans for 30/06/08 individual residents must be audited and evaluated to ensure that they accurately reflect their current care needs and the action to be taken by staff to meet assessed care needs of people living in the home. The outcome of the audit will ensure that residents care needs are being met and promote their wellbeing. All residents must have access to 30/06/08 specialist services to support meeting their care needs. This must include residents who are losing weight and need support with meeting their nutritional needs. All residents must have their 30/06/08 weight monitored at a frequency that allows appropriate monitoring of weight gain or loss depending on their individual assessed needs. This will allow appropriate DS0000004260.V358609.R01.S.doc Version 5.2 Page 33 Waterloo House 5 OP8 OP10 12 6 OP9 13(2) 7 OP9 13(2) and timely action to be taken and protect the wellbeing of people living in the home. Due care must be taken to ensure 30/06/08 that resident’s are supported to meet their personal hygiene needs. This will ensure that they are clean and suitably dressed to meet their needs at all times and appropriate for the time of year, hence protecting their dignity and wellbeing. The registered manager must 30/06/08 make suitable arrangements for regular audits to take place of medicines held in the home to ensure that it is being safely administered, stored and disposed of. Not assessed at this inspection. Timescale 30/10/06 & 19/12/07 The correct medicine must be 30/06/08 administered to the correct service user at the correct time and dose and records must accurately reflect practice. This is to ensure the health and well being of the service users within the home. Not assessed at this inspection. Timescale 20/01/08 The purchase and installation of a Controlled Drug cabinet that complies with the Misuse of Drugs (safe custody) Regulations 1973 as amended to safely store, any Controlled Drugs on the premise is required. Not assessed at this inspection. Timescale 20/01/08 A system must be installed to check the prescription before they are dispensed and to check the dispensed medication and medicine charts received into the home for accuracy and any DS0000004260.V358609.R01.S.doc Version 5.2 8 OP9 13(2) 30/06/08 9 OP9 13(2) 30/06/08 Waterloo House Page 34 10 OP9 13(2) 11 OP9 13(2) 12 OP9 13(2) 13 OP29 18 Sch.2 discrepancies addressed before the start of the 28-day cycle. This is to ensure that the service users receive their medicines as the doctor intended Not assessed at this inspection. Timescale 20/01/08 All medicine must be available for administration recently prescribed, recorded on the medicine chart and be in date. This is to ensure protect the health and well being of the service users. Not assessed at this inspection. Timescale 20/01/08 The installation of cabinets to house the medicines within the walk in cupboards is required. This is to ensure that all medicines are safely held in the home and no unauthorised people who live in the home have access to them Not assessed at this inspection. Timescale 20/01/08 Any medicine prescribed on a when required basis must have supporting protocols to ensure they are administered as the doctor intended. Not assessed at this inspection. Timescale 20/01/08 Sufficient information must be secured to determine the fitness of potential employees before they start working at the care home. To include: • Two written references, including where applicable, a reference relating to the person’s last period of employment, which involved work with vulnerable adults. • A full employment history, together with a satisfactory written explanation of any gaps in employment. DS0000004260.V358609.R01.S.doc Version 5.2 30/06/08 30/06/08 30/06/08 30/06/08 Waterloo House Page 35 14 OP38 23, 13 This will ensure that the home’s staff recruitment practices safeguard people living in the home. The standards of health and safety management within the home must be reviewed. This should include: • Access to the conservatory must be reviewed so that care staff are not tilting residents backwards in chairs to get in to the conservatory. The uneven floor in the corridors of the main home. Must be reviewed to level and safe for residents and staff to walk on. Equipment and aids used by people living in the home must have ongoing maintenance and servicing to ensure that they are fit for purpose. Food must not be stored in the large storage bin situated in the grounds outside the kitchen. 30/06/08 • • • This will ensure that people who use the services are protected from the risk of harm. 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 OP1 Good Practice Recommendations The Statement of Purpose and Service User Guide should be updated and available in alternative formats. This will DS0000004260.V358609.R01.S.doc Version 5.2 Page 36 Waterloo House 2 OP7 3 4 OP9 OP9 5 6 OP10 OP14 7 OP8 OP15 8 OP15 9 OP16 10 OP19 11 OP20 ensure prospective residents have all necessary information to enable them to make an informed decision about using the home. Written entries in resident’s care files should be dated, timed and signed with the person’s signature. This will ensure that a legible and effective audit trial is available to track the care given to people living in the home. It is recommended that service users have regular medication reviews in line with the national service framework It is recommended that additional trolley are purchased to house all the service users current medication so all medicines are available to offer at the time of the medication round. Staff should ensure that residents are suitably dressed at all times. This will support residents to maintain their dignity. Evidence should be available to show how residents’ representatives are supported to help them to exercise control and choice in their day-to-day life. This will ensure that residents are able to maintain their independence based on their own life’s experiences. The support and guidance of speech and language and dietician services should be sought regarding providing suitable, nutritious and appropriate meals for residents noted to have lost and are still losing weight, meals and types of food suitable for residents with dementia and the preparation of soft food meals. The mental health state of people living in the home should be considered when asking them about their choose of meal. Consideration given to how and when they are asked and an assessment made as to whether it is a suitable method. For example, will the introduction of photographs of meals help residents? Responses to complaints should be audited to ensure that all issues have been dealt with effectively and a detailed response is given to the complainant. This will help to ensure that residents are confident that their complaint will be taken seriously. Details and plans for ongoing refurbishment in the fabric of the home, updating of the décor and replacement of furniture should be maintained in the home. This will ensure that residents are living in a homely, attractive and well-maintained home environment. Shared bedrooms should clearly define two separate living areas where two people that do not know each other, but have decided to share bedroom facilities. This will help to ensure privacy and promote residents quality of life. DS0000004260.V358609.R01.S.doc Version 5.2 Page 37 Waterloo House 12 OP21 13 OP22 14 OP22 15 OP26 16 17 OP26 OP27 18 OP30 19 OP31 A review of the bathing facilities should be added to the ongoing maintenance and refurbishment programme for the home. This will ensure that there are suitable bathroom and shower facilities on each floor, which are easily accessible by people living in the home. Aids and equipment used in the home to support the health and wellbeing of residents should be regularly and suitably maintained and serviced to ensure that it is fit for purpose and safeguards residents from the risk of harm. Access to areas of the home, must be reviewed to ensure that people living in the home are able to occupy rooms provided for their use, safely. This includes the conservatory, en-suites, toilets, and bathrooms. A review should be carried out of the organisation and procedures in the laundry to ensure that safe practices can be maintained by care staff when undertaking laundry duty. This will help to ensure residents’ clothes are appropriately laundered, promoting their wellbeing and that residents are living in a clean, safe and healthy environment. A review should be carried out of the storage of food in the large bin in the grounds outside the kitchen. This will ensure residents are protected from risk of harm. Staffing levels should be reviewed to ensure that sufficient numbers are on duty at all times. Attention should be given to peak times of activity in the home, which includes mealtimes, and the involvement of staff in domestic duties. This will ensure that residents care needs can be met safely at all times. All staff must receive training appropriate to the health; personal and health care needs of the people in their care and the long term plans of the organisation. For example Dementia, care. This will ensure the safety of people who live in the care home, that staff are trained, and competent to meet their care needs. The manager must ensure that all care practices in the home are appropriately monitored to promote the health and wellbeing of people living in the home. This must include a review and audit of the management of medication. Group supervisions should not take the place of individual supervision of care staff working in the home. This will ensure that all staff receive appropriate supervision to identify their competency level and individual training needs are identified. 20 OP36 Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Waterloo House DS0000004260.V358609.R01.S.doc Version 5.2 Page 39 - 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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