Inspection on 29/09/05 for Waterloo House

This inspection was carried out on 29th September 2005.

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 01/08/08

Waterloo House 22/06/07

Waterloo House 12/06/06

Waterloo House 29/11/05

Waterloo House 23/11/04

Waterloo House 23/06/04

Similar services:

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West View House

Moor House

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Park View (15)

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 Blyth Northumberland NE24 1BY Lead Inspector Carole McKay Unannounced Inspection 29th September 2005 10:15 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 DS0000000639.V252489.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Waterloo House Address Waterloo Road Blyth Northumberland NE24 1BY 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) 01670 351992 01670 356328 Mr Sewa Singh Gill Mrs Brenda Nicholson Care Home 46 Category(ies) of Dementia - over 65 years of age (12), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (33) Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2004 Brief Description of the Service: Waterloo House is a two storey adapted building. The home does not have gardens, though a small sitting out area is located near the front entrance to the home. Parking for a small number of cars is available at the front of the home within a general amenity area. The home is well located, in walking distance of the centre of Blyth. Bedrooms and communal areas are distributed across both floors and the office/reception area is immediately inside the main entrance hallway. The home has a large established staff team of ancillary, care, and senior care staff plus one manager. Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 6 hours and was carried out to monitor progress in meeting requirements and recommendations made at earlier inspections. A partial tour of the premises took place and some of the staff and care records were inspected. Five of the staff on duty and eight of the residents were spoken to. What the service does well: What has improved since the last inspection? Action has been taken to improve dignity and privacy for service users. All service users can now safely lock their room doors if they wish. Incontinence supplies are more discreetly stored around the home. Aids are being used to encourage people with dementia to retain their independence and to exercise choice. The main corridors and bedroom doors have been redecorated and the home has a fresher, cleaner feel. Repairs have been made to the damaged facilities and ventilation in the ironing room has improved. Staff knowledge and skills in working with people with dementia have improved through special training and staff feel more confident in caring for Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 6 this client group. Staff were observed to involve confused service users in meaningful activity in a positive manner. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Service user’ needs are assessed prior to admission to the home. A brief pre admission assessment and care plan is devised from this. Following admission a more detailed plan of care is produced based on a review of a person’s needs. EVIDENCE: A copy of the care management assessment and care plan had been obtained for a service user who was due to be admitted on the day of the inspection. For two service users who had been at the home for several weeks, a review of their needs had been carried out. These were detailed in the files the Inspector examined. Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,10 A care planning system is in place for providing staff with the information they need to meet the assessed needs of the people living in the home. These are not developed consistently. The privacy and dignity of service users is protected. EVIDENCE: One of the files, which the inspector looked at, did not contain a risk assessment and management plan. In response to requirements made following the previous inspection, suitable door locks have been fitted to bedroom doors. Extra storage has been created for supplies of incontinence aids. Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 The Home provides a relaxed informal environment in which people are supported to exercise choice and control over their lives, so that, as far as possible, they contribute to the running of the home and are consulted over where and who with they spend their time, and make choices about what they eat and drink. The registered manager is taking steps to ensure that people living at the home, who have dementia, maintain their independent living skills by use of pictures and photographs. EVIDENCE: The Inspector observed staff offering choices to service users about morning refreshments. Service users told the Inspector that staff were very good and that they “couldn’t ask for more”. The Inspector observed one service user being assisted to answer the telephone in the hall and helping with collecting coffee cups. The home has an open visiting policy and relatives and friends of the people living at the home make good use of this. The visitor’s book is located in the main hall and several visits were recorded for each day of the week preceding the Inspection. During the inspection two people called at the home for a look around on behalf of a relative. The staff were friendly and helpful in their manner towards these people and refreshments were offered. Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 11 Service users told the Inspector that they were able to use any lounge. Two of the ladies in the ground floor lounge said that they preferred that one because it had large window and was light with a nice view. The registered manager has had photographic signage and menus made, to enable people who have dementia to find their way around and to make choices at mealtimes. Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home takes steps to protect service users from abuse by educating its staff and taking steps to prevent unsuitable people from working in care settings. EVIDENCE: There is evidence in the staff records that the home will respond promptly and appropriately to incidents of abusive behaviour by staff members. The manager has had cause to use the local protection procedures on one occasion. The registered persons have not reached a decision whether they will be referring a person they dismissed form employment to the Secretary of State The home has various policy documents that deal with abuse, whistle blowing, physical intervention, restraint and handling service users’ finances. The manager has introduced teaching pack offering guidance and information for staff on the subject. Each member of staff has been issued with the pack. Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,26 The home is clean and the general maintenance of the décor has improved. Service users are aware that some items of furniture detract from the presentation and comfort of the home. Service users on the first floor cannot access an assisted bathing facility without going downstairs EVIDENCE: The home was clean throughout and without bad odour. Two cleaning staff were on duty at the time of the inspection. The Inspector spoke to both staff and they said that they were able to undertake their duties in the time allocated to them. Suitable door locks have been fitted to service users’ rooms. A requirement was made at the previous inspection that an additional bathing facility must be installed on the first floor. This has not been completed to the given timescale and is now outstanding. Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 14 The manager said that arrangements were being made for the handyman to install a specialist bath and an additional shower. The lifting device had not yet been installed. A matter of ventilation in the ironing room has been addressed by installing an automatic air extractor. The laundry assistant said that this had made some improvement to her working conditions. A repair has been made to a bath panel on the ground floor in response to requirement in the previous report. The registered manager has consulted with the visiting fire officer concerning installations to hold open the fire doors on service users’ rooms. Suitable installations have not been purchased. Some of the furniture in the home is very worn and has not been replaced. A bed in the shared room on the first floor has a damaged base and the wooden frame is exposed. The varnish finishes on the wood frame on chairs in the ground floor lounge are worn away and the upholstery very stained. The upholstery on one of the chairs in the ground floor smokers’ lounge is torn. When asked what improvements could be made at the home two service users said that some of the chairs did not look nice. Areas of the home have been redecorated over recent months, however the walls of the dining room on the first floor are marked and the paint is peeling in places. A combination lock has been fitted to the door leading to the staircase on the first floor, as a safety measure to prevent a person with poor vision from accessing the stairs and risk falling. The visiting fire officer has not approved this arrangement. Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29, 30 The home maintains its staffing levels, however of late this has been done without keeping to robust recruitment procedures. EVIDENCE: The home has experienced an unusual level of staff turnover since the last inspection. During this period the Manager has maintained staffing levels by and home staff working extra hours or employing agency staff when necessary. At the time of the inspection the home had a full compliment of staff. One of the staff most recently employed said that she had received basic induction training, and this was recorded in the staff file. Staff recruitment procedures are not robust. Application forms are used and Criminal Record Bureau checks had been requested, however on two of the files examined only one written reference had been taken up. There was no evidence on file that gaps in employment history had been explored and no record of interviews had been kept. No conformation of identity was recorded on either of the files. Since the last inspection, as a condition of a variation to categories of registration, the Manager and twenty of the care staff have undertaken specialised training in caring for people with dementia. The Manager and one of the senior staff said that the training had been valuable and were able to give examples of how it improved care practice. Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37, The staffing resources and day-to-day care of service users is well managed. The comfort, safety and financial security of service users are not so well safeguarded. EVIDENCE: The Manager is registered with The Commission for Social Care Inspection and holds The Registered Managers’ Award. Since the last inspection the Manager, Brenda Nicholson, has undertaken specialised training in dementia care mapping. Following the last inspection of the home a requirement was made that the registered persons devise a quality assurance system. This has not been addressed. One result of this is that requirements to do with improvements to the fabric of the building remain outstanding beyond timescales given for completion. Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 17 A representative of the Registered Owner makes suitable monthly visits to the home. Reports from these visits are produced and made available to the Inspector. The home has a clear policy regarding the handling of service users’ personal finances. The Manager told the Inspector that she was not acting as agent or appointee for any person living at Waterloo House and that neither the Manager or the staff deal with service users’ bank accounts. Cash belonging to service users is held for safekeeping and securely stored in the safe, if this is in the interest of service user’, or is a personal preference. The Inspector examined the records of expenditure. These were maintained in individual separate records and purchases were properly recorded and receipts were kept. Although it is the policy of the home that two staff sign the record, in some instances only one signature was entered. Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 2 2 X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 2 X X 2 Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 19 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 OP33 Regulation 24 Requirement The Registered Persons must establish in the home a quality assurance system, with the following outcomes: The views of service users and of GPs, Community Nurses, Care Managers to be sought on how the home is achieving goals for service users An annual development plan for the home reflecting aims and outcomes for service users Action is progressed within agreed timescales to implement requirements identified in inspection reports The quality of the premises, furniture and fittings to be consistently maintained to a good standard. (Previous timescale of 30.06.05 not met) Risk assessments must be carried out for each person admitted to the home and a DS0000000639.V252489.R01.S.doc Timescale for action 21/11/05 2 OP7 14 31/10/05 Waterloo House Version 5.0 Page 20 3 OP21 23 management plan accompany the assessment where risks are identified The Registered Persons must install an additional assisted bathing facility on the first floor. A specialist engineer must commission any lifting device before being used. The Registered Persons must arrange for safe systems to be installed for the holding open of fire doors, in line with guidance form the fire officer. The Registered Persons must inform the fire officer about the fitting of the combination lock. The following items of furniture must be replaced: Wood frame chairs in the ground floor lounge The damaged single bed in the shared room on the first floor The damaged chair in the smokers’ lounge on the ground floor 31/10/05 4 OP38 23 31/10/05 5 OP20 23 31/10/05 6 7 OP19 OP29 23 19 Schedule 2 The dining room on the first floor must be redecorated The Registered Persons must gather and keep a record of the following for each member of staff as part of the recruitment process: Proof of the person’s identity Two written references relating to the person 31/10/05 31/10/05 Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 21 No. 1 Refer to Standard OP18 Good Practice Recommendations The Registered Persons should reach a decision whether they intend to refer the staff they dismissed to the Secretary of State and document the decision, with reasons, in the staff member’s file. As good practice the Registered Persons should keep records of staff interviews and demonstrate that gaps in employment history are explored at interview. As good practice staff dealing with service users’ monies should obtain two signatures for each transaction, in line with the policy in the home. 2 3 OP29 OP18 Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Waterloo House DS0000000639.V252489.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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