CARE HOME ADULTS 18-65
Waterfall House 363-365 Bowes Road London N11 1AA Lead Inspector
Jane Ray Key Unannounced Inspection 26th June 2006 11:00 Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Waterfall House Address 363-365 Bowes Road London N11 1AA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8368 1710 Mr Haresh Dhunnoo Mrs Marina Dhunnoo Care Home 27 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (27) of places Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Not to exceed 18 Adults of either gender with a mental disorder, excluding learning disability or dementia (MD) at Waterfall House 363/365 Bowes Road, New Southgate, London, N11 1AA Not to exceed 4 Adults of either gender with a mental disorder, excluding learning disability or dementia (MD) at 24 Brookdale, New Southgate, London, N11 1BP (satellite) Not to exceed 5 Adults of either gender with a mental disorder, excluding learning disability or dementia (MD) at 26 Brookdale, New Southgate, London, N11 1BP (satellite) Eleven specified service users who are over 65 years of age may remain accommodated in 363/365 Bowes Road. The home must advise the regulating authority at such times as any of the specified service users vacate the homes. One specified service user who is over 65 years of age may remain accommodated in 26 Brookdale, Waterfall House. The home must advise the regulating authority at such times as any of the specified service users vacates the home. 8th November 2005 2. 3. 4. 5. 6. Date of last inspection Brief Description of the Service: Waterfall House is a care home registered to provide support and accommodation to 27 adults of either gender with mental health problems. The homes service user guide states that Waterfall House offers rehabilitation to those with a mental illness with a view to living an ordinary life in the community. Waterfall House consists of three separate units: 363/365 Bowes Road accommodating 18 service users, 24 Brookdale accommodating 4 service users and 26 Brookdale accommodating 5 service users. Twelve service users are over the age of 65. The registered person has a variation of conditions on their registration in respect of these service users. The building in Bowes Road consists of two-semi detached houses, which have been connected internally and extended to provide additional living space. 2426 Brookdale are both ordinary suburban semi-detached properties positioned next to each other and about five minutes walk from Bowes Road. The home was opened in 1998 with seven service users all around 50 years of age. In
Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 5 1992, 24 Brookdale opened and a few years later 26 Brookdale was opened these homes are for more independent service users. Waterfall House is a home for life but service users can move on if they choose to. The properties have well maintained front and back gardens. Local shops and all other amenities are close by. Arnos Grove tube station is five minutes walk away. Bowes Road is staffed 24 hours a day, whilst the two houses in Brookdale are staffed for a few hours during the day and are unstaffed at night. Service users can contact Bowes Road for support if needed. At the time of the inspection there were 23 service users living in the service. The current range of fees in the home is from £277 - £442 a week. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 6 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place on the 26 June 2006 and was unannounced. The inspection lasted for six hours and was the main annual inspection. The inspection looked at how the home was performing in terms of the key National Minimum Standards for Younger Adults and the associated regulations. The inspector was able to meet, speak to and observe the support given to the current service users. The inspector was also able to spend time talking to the registered provider and manager and two members of care staff who were working in the home. The inspector did a tour of the premises and also looked at a range of records including service users records, staff files and health and safety documentation. The home had also prepared a pre-inspection questionnaire that provided information for the inspector. What the service does well:
The service users benefit from a service that has experience in supporting people who have enduring mental health issues and offers a professional, stable and supportive environment for them to live. The service users all benefit from a comprehensive assessment and individual care plans that are regularly reviewed. These enable each service users individual needs to be met. The home has good working links with health care professionals including the mental health service that enables the service users to be supported with their healthcare issues. The home welcomes relatives and other friends and supports service users to maintain relationships. The service users all feel able and comfortable to express their views on how the home is working and anything they need or want to happen. The home operates professional policies and procedures including those relating to staff recruitment and management, health and safety and medication. These help to safeguard the service users. The homes are well located to enable the service users to access local shops and other amenities.
Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 7 What has improved since the last inspection? What they could do better:
There are two outstanding requirements from the previous inspection. In both cases work had been started to meet the requirement but was not fully complete. Firstly the adult protection procedure needs some further work to ensure the procedure for reporting abuse reflects local arrangements. Secondly staff fire safety training has been booked but has not yet taken place and the date of the training needs to be confirmed. The other main area for improvement relates to the support provided at Bowes Road. It was observed during the inspection that this home had rather a fixed routine and that the staff were often carrying out tasks for the service users rather than encouraging them to do things for themselves. This does reflect the backgrounds and ages of many of the service users who have had many years in institutional care and who are very happy with the routine and input offered by the staff. The inspector is not suggesting any major changes but would like to see some individual work with service users as appropriate to develop their skills and allow them to have more flexibility in the home. Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 8 There are also some service users at Bowes Road who hardly ever go out and the inspector felt that they should receive some more individual support to enable them to access community facilities. The contracts between the home and the service users need to have the correct fee level. The service users at Brookdale need individual inventories completed. The service user who has PRN medication needs individual guidelines stating when this medication should be administered. Soap and hand towels must be available in all shared toilets. At Bowes Road there are some environmental improvements identified including replacing the carpet in the downstairs hallway, replacing strip lighting with more homely lighting and providing a larger television in the lounge. For staff, their individual contracts all need to have the correct hourly rate of pay and all other contractual information completed. The staff also need to receive up to date training on the protection of vulnerable adults. The provider and manager need to add to the current quality assurance exercise and seek the views of relatives, care professionals and other people associated with the home. Any feedback will need to be incorporated into an action plan for 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. Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 10 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4 and 5 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. Service users can be assured that their needs will assessed at the time of their admission to the service and that they will have an opportunity to visit the service as part of their admission process. They will also be offered clear information about the service. Each service user has a contract with the home but these must include the correct fee. EVIDENCE: The statement of purpose and service user guide were inspected. The statement of purpose has been updated and includes all the necessary information. The service user guide is clear and provides all the details needed by the service users. There has been one service user admitted to the service since the last inspection. The assessment information was inspected for this service user. This was seen to be very thorough and included reports from a psychiatrist, district nurse and the home where the service user had previously lived. The staff were able to explain to the inspector that this service user had made a visit to the home as part of the admission process. The inspector looked at the contracts between the home and four service users. These documents were all available but they did not include the correct weekly fee and this needs to be amended.
Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 and 9 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. Service users are supported to have their individual needs met by robust care plans and risk assessment that are reviewed on an ongoing basis. Service users feel able to contribute their views on the operation of the home EVIDENCE: Four service user care plans were inspected. They each contained a detailed assessment completed by the home covering the physical, social and emotional needs of each service user. From the assessments the manager had developed care plans and risk assessments. The care plan goals are clear and achievable and are focused on the specific needs of the individual. These goals are reviewed every six months and an update is provided on how each service user is progressing. Each service user has a record of a review meeting in the previous year with a psychiatrist or care manager. Each service user has a key worker and staff and service users know about the key working system. The risk assessments were inspected for each service user. These are all reviewed on a three monthly basis and reflect each service users individual needs. Where the risk assessment identifies the need for more detailed
Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 12 guidance then this is available. For example one service user had a history of absconding and guidelines for staff were available on how the service user should be supported with this issue. The four service user case notes that were inspected all contained a clear explanation of how each service user is supported to manage their personal finances. Two service users are assisted by the Court of Protection. The four case notes were all very well organised and contained clear sections so that all the information could be easily found. The manager explained that none of the service users have an advocate at the present time. Service user meetings take place every two or three months and the manager said that these are very informal which the service users prefer. The inspector spoke to ten of the service users. Two commented on how they always feel able to raise any concerns with the manager or owner. It was also observed throughout the inspection that service users interacted with the manager and staff on any issues that they needed to have addressed. Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the visit to this service. Service users can be assured that their privacy will be respected and that they will be supported to maintain relationships and to pursue their individual interests. Service users who lack self-motivation need more support to leave the home and to follow a lifestyle based on their individual wishes rather than just the routine of the home. EVIDENCE: The inspector spoke to the service users and staff, whilst also observing the routine in the home. A few service users, when their mental health permits are able to carry out domestic chores in the home. One service user was able to tell the inspector how much she enjoyed preparing her own snacks and another said she cooked for her son when he visited. It was however observed that the staff are very efficient and carry out most of the domestic activities and one service user said that she occasionally asks to help and all the work is done. The staff need to look for opportunities to support the service users to further develop their individual living skills.
Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 14 The manager was able to describe how the home helps the service users to practice their religions and cultures. One service user is practising Muslim and the home buys him halal meat and he takes himself to the temple. One service user who is Hindu has chosen to eat a vegetarian diet. A Chinese service user eats rice with most of her meals and the Greek service user also enjoys traditional food. Four of the service users are practising Roman Catholics and attend church on a regular basis. The staff team is also very multi-cultural. The manager explained that four of the service users choose to attend a day centre on a regular basis and one also goes to college one evening a week. The inspector looked at the activities recorded in the daily log for four service users and it was noted that three had not gone out of the home in the previous ten days. These service users need to be encouraged to access community based facilities. The manager explained that whilst a number of service users have expressed an interest in going on a holiday they do not have enough personal finances to pay for this. The registered provider has contacted the purchasing authorities to request additional funding to cover the cost of the holiday but has not succeeded in obtaining this funding. The manager and staff explained that ten of the service users have regular contact with their relatives and they either go to visit them or the relatives come to the home. Three service users were able to tell the inspector how their relatives come to visit them and that they are made welcome at the home. The inspector spoke to three service users about the routine in the home. They explained that the breakfast is at 9am. They also said that at 8.30pm when the night staff come on duty most of the service users go to their rooms. The service users said they were happy with this routine and that they did not necessarily go to bed at 8.30pm but might listen to music or watch television in their rooms. The inspector could see that the routines in the home were quite set and that where possible service users should be encouraged to express choice about how they want to spend their time during the day. The home has a menu that is agreed with the service users. The inspector looked at the menu for the week of the inspection and whilst this was rather traditional it did appear to be nutritious. The service users spoken to said they enjoyed the food. Two service users said they were able to prepare their own food if they wished to do so. A record is kept of any variations from the usual menu. Service users are also supported to check their weight each month and this is recorded so that any variations in weight can be addressed. The service users were observed eating lunch and this took place in a relaxed manner. Hot drinks were also served throughout the day. The service users who live at Brookdale are able to have a cooked lunch at Bowes Road during the week but have a separately cooked meal in the evening.
Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the visit to this service. Service users are supported to receive personal care according to their individual needs. They also receive support to access healthcare support. The medication is administered safely in the home although service users who have PRN medication need to have guidelines on when this should be administered. EVIDENCE: It was observed during the inspection that the service users were given support with their personal care based on their individual needs. The service users were all adequately dressed and groomed. Two service users were able to tell the inspector how a hairdresser comes into the home although some service users use the local hairdressers or ask the staff to cut their hair. It is recommended that as far as possible service users are supported to use the hairdressers in the local community as part of their community participation. The healthcare records were inspected for four service users. They had all been supported to access the GP, dentist, optician and chiropodist for their primary healthcare checks. They all see the consultant psychiatrist on a regular basis. In addition service users attend outpatient appointments for their specialist healthcare needs.
Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 16 The medication systems in the home were inspected. The home uses a blister pack system provided by the local pharmacist. The service users at Bowes Road have their medication administered by staff but at Brookdale most of the service users self-medicate. The medication was appropriately stored and the temperature of the medication cupboard was recorded daily. The medication administration records were completed correctly. The medication entering the home is recorded appropriately on the medication administration record. One service user has PRN medication and there are no guidelines in place explaining when the medication should be administered. Staff have received medication training and certificates were seen in four staff files. Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made from evidence gathered during the visit to this service. Service users are confident that they know how to complain and their views will be acted on. Service users need to be protected from abuse by ensuring all the staff have received adult protection training and by the homes abuse policy containing all the necessary information on how to report an allegation. EVIDENCE: The inspector looked at the complaints procedure. This procedure is clear and contains the necessary information and is displayed by the service users telephone. The manager explained that there have been no complaints received since the last inspection. Two service users told the inspector that if they had any concerns they would feel happy to talk to the manager or the staff on duty. The inspector looked at the adult protection procedure. This did not clearly explain how an allegation should be reported in line with local adult protection procedures. The manager is attending adult protection training provided by social services and will then be able to amend the policy. Four staff training records were inspected and none of the staff had a record of receiving training on adult protection. This training needs to be updated for all the staff. The inspector looked at the records for the service users personal finances. The manager explained that each week the service users are given their personal allowance and they sign to say this has been received. The manager said that they do not hold any money on behalf of the service users.
Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 18 Since the last inspection inventories have been completed for the service users at Bowes Road. It is recommended that these are also introduced at Brookdale. Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 19 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered during the visit to this service. The service users live in a safe and clean environment that is maintained on an ongoing basis. Further work is required to keep the homes appropriately maintained and homely. EVIDENCE: The inspector did a tour of the three homes. Since the previous inspection the service has prepared a building maintenance plan and the stair carpet at 26 Brookdale has been replaced and decoration has taken place in the hallways at Bowes Road and in the downstairs bathroom and toilet. A mattress in a downstairs bedroom at Bowes Road has been replaced. During the inspection the lounge at Bowes Road was being redecorated. Some areas for improvement identified at this inspection at Bowes Road include replacing the downstairs hallway carpet, replacing the strip lighting and providing more domestic lighting and providing a larger television in the lounge to ensure it can be seen by the service users.
Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 20 The homes were all observed to be extremely clean and tidy. The upstairs shower and toilets at Bowes Road were observed not to have any soap or hand towels and these need to be provided. Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 21 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 Quality in this outcome area is good. This judgement has been made from evidence gathered during the visit to this service. Service users will be supported by a stable team of staff who have undertaken the appropriate recruitment checks and are supervised on an ongoing basis. Staff need to be given comprehensive contracts of employment. EVIDENCE: The rota was inspected and discussed with the manager. From 7.30am until 8.30pm there are two staff on duty at Bowes Road. At Brookdale there is one member of staff on duty for seven and a half hours during the day. At night there is one member of staff awake at Bowes Road and Brookdale does not have staff but the service users can contact Bowes Road if they need assistance. Since the last inspection two part-time staff have left and the other staff have been working additional hours at their request. The manager is in the process of appointing additional part-time staff. There are eight staff employed in the service. Two have completed NVQ’s in care and two are studying for the qualification. This means that 50 of the staff either have or are studying for the qualification. Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 22 The staff team have a meeting every two or three months. The records of these meetings were inspected and show that the staff are discussing a range of operational issues relating to the homes. The staff files were inspected for four members of staff. The staff all had the appropriate recruitment checks in line with a professional recruitment policy. The staff had all completed applications, had two written references, a CRB disclosure and where necessary had evidence of a visa. The staff contracts of employment were in each of the staff files but these had not been completed giving the hourly rate of pay and other information such as their annual leave entitlement. The induction records were inspected for the two most recently recruited members of staff. They have completed an induction booklet that is comprehensive and incorporates TOPPS guidelines. The staff supervision records were inspected for four members of staff. All the staff have received regular individual supervision and the records were inspected. The supervision looks at the performance of the staff and their development needs. Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 23 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. 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 from evidence gathered during the visit to this service. The service users are benefiting from living in a well managed service where the focus is on providing a high standard of care. Health and safety measures to protect the service users are in place. The quality assurance work needs to also seek the views of relatives and other healthcare professionals. EVIDENCE: The home has a registered manager. The manager has the appropriate skills and experience and has also completed the NVQ level 4 in management of care and is waiting for her work to be verified. Since the last inspection the home has completed a quality assurance exercise. This has involved asking service users to complete questionnaires asking for feedback on the service. The results of these questionnaires have been collated but there was no significant action identified from the responses. The quality assurance exercise needs to also seek the views of relatives and other healthcare professionals who are stakeholders in the service.
Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 24 Fire safety measures are in place apart from staff training. The fire safety records were inspected in Bowes Road and Brookdale and weekly fire alarm checks and monthly fire drills are recorded. On the day of the inspection the fire doors in the home were closed. The fire alarm and extinguishers had received their service and records were available to confirm this had taken place. The home has a fire safety risk assessment. The staff have still not received their updated fire safety training and the training provider has been identified but a training date is not yet confirmed. The requirement for staff to receive this training is restated from the previous inspection. The certificates were in place to confirm the gas system and electrical installations and portable electrical appliances had been serviced in all the houses. The current insurance certificate was displayed and was satisfactory. The staff training records were inspected for four staff and they had received appropriate health and safety training including first aid and food hygiene. Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 25 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 x LIFESTYLES Standard No Score 11 2 12 3 13 2 14 3 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 2 x x 2 x Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 5(1)(b) Requirement The registered person must ensure the contract between the home and the service user includes the correct fee. The registered person must ensure that service users are supported to carry out independent living skills for themselves rather than relying on the staff. The registered person must ensure that all the service users receive support to access community based facilities if they are unable to do this independently. The registered person must ensure that the service users are supported to develop their own lifestyles and have flexibility of routine. The registered person must ensure that the one service user who has PRN medication has guidelines in place stating when this medication should be administered. The registered person must review the adult protection procedure to ensure that clear
DS0000010684.V292108.R01.S.doc Timescale for action 31/07/06 2. YA11 12(1) 15/08/06 3. YA13 16(2)(m) 15/08/06 4. YA16 12(1) 15/08/06 5. YA20 13(2) 31/07/06 6. YA23 13(6) 31/07/06 Waterfall House Version 5.1 Page 27 7. YA23 13(6) 8. YA24 23(2)(b) 9. YA30 13(3) 10. YA34 17(2) 11. YA39 24(1)-(3) 12. YA42 23(4)(d) reporting procedures are in place for staff in line with local adult protection procedures. This requirement is amended and restated from the previous inspection as the previous timescale of 01/02/06 was not met. The registered person must ensure that all the staff receive up to date training on the protection of vulnerable adults. The registered person must complete the building improvements identified in the environment section of the report. The registered person must ensure that soap and hand towels are provided in all the communal toilets. The registered person must ensure that all the staff have completed contracts of employment. The registered person must ensure the quality assurance exercise also includes the views of relatives and other stakeholders such as healthcare professionals. The registered person must ensure that all staff receive refresher fire training and that this happens annually. This requirement is restated from the previous inspection as the previous timescale of 28/02/06 was not met. 15/08/06 30/09/06 31/07/06 31/07/06 30/09/06 15/09/06 Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA18 YA23 Good Practice Recommendations The registered person should encourage the service users to access community based hairdressers. The registered person should complete inventories for the service users at Brookdale. Waterfall House DS0000010684.V292108.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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