Inspection on 05/09/05 for Waterloo House, St Mawes

This inspection was carried out on 5th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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, St Mawes 14/11/08

Waterloo House, St Mawes 07/12/06

Waterloo House, St Mawes 08/03/06

Waterloo House, St Mawes 19/01/05

Waterloo House, St Mawes 05/07/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Waterloo House Upper Castle Street St Mawes Cornwall TR2 5AE Lead Inspector Ian Wright Announced 5 September 2005 14:00 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 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 Stationary 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 D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Waterloo House Address Upper Castle Street St Mawes Cornwall TR2 5AE 01326 270570 01326 270570 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Royal Mencap (Housing & Support Services) Ms Lorna Jane Pooley Care Home 8 Category(ies) of Learning Disability (8) registration, with number of places Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19.1.05 Brief Description of the Service: Waterloo House is situated in the village of St Mawes on the Roseland Peninsula. The home provides care and support for up to 8 adults with learning disabilities. The home is a large detached property with sizable grounds. All service users have their own bedrooms. The home has a large lounge, dining room, and appropriate bathroom and toilet facilities. The home also has an activities room in the grounds. The garden and the ground floor of the building could be used by wheel chair users. The registered manager is Ms Lorna Pooley. Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over seven and three quarter hours. The inspection was carried out on an announced basis. The inspector was able to speak to the majority of service users, the relative of a service user and the registered manager. The inspector examined care and business records, and inspected the building. What the service does well: What has improved since the last inspection? What they could do better: Kitchen units still need to be replaced. Some of the external and internal decorations need to be completed although the registered manager said this would be completed by the end of the year. Where staff keep monies on service users’ behalf a risk assessment must be completed, and reviewed regularly, to ensure no unreasonable restrictions are placed on individual service users. Mencap’s complaints procedure must be amended to state complainants can contact the Commission for Social Care Inspection at any time. The policy Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 6 must give details of how to contact the Commission. Mencap’s policy regarding death and dying also still needs to be expanded to include how the provider will adjust service user’s care packages (if appropriate) to take into consideration the aging process. 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 D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1-3 The registered manager provides suitable information to assist service users and their representatives to make an informed choice about moving to the home. Suitable links are maintained between staff and other external professionals to ensure service user needs are met. EVIDENCE: A suitable statement of purpose and service user guide was inspected. The registered manager said these had been issued to service users, and where appropriate, their relatives. The registered provider has a satisfactory pre admission assessment procedure. There have been no recent admissions. The registered manager stated suitable links have been established with external professionals such as community nurses, general practitioners and social workers. Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 9 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 standard(s) 6, 9, 10 Appropriate policies and procedures, and documentation is in place regarding care planning and risk assessment. Documentation is stored confidentially. EVIDENCE: A copy of a care plan is contained in each service user’s file. These are reviewed appropriately. Risk assessments are maintained on each service user’s file, and these are reviewed appropriately. However where money is kept on behalf of service users, a risk assessment must be completed and regularly reviewed, to ensure unreasonable restrictions are not placed on service users access to their monies. The registered manager said service users are encouraged to take suitable risks such as going out on their own. All information is stored confidentially. Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 10 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 standard(s) 11, 12, 14-17 Suitable opportunities are provided for service users to develop their skills, be part of the community, and generally have a wide range of day activities available to them. Contact with service users family and friends are encouraged. Suitable arrangements are in place so service users have a varied and healthy diet. EVIDENCE: The registered manager said suitable links with appropriate services (e.g. psychologist) have been developed to assist service users to develop communication, emotional and social skills. Service users have appropriate opportunities to develop their independence for example they are involved in cooking, and other household tasks. Some service users can go out on their own and use public transport. The registered manager and service users said they are given suitable opportunities to participate in the community for example village events, and using local facilities such as colleges, leisure centres, pubs and clubs. However the activities of one service user was limited. Although the reasons for this are Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 11 complex, and not necessarily the fault of the registered persons, the registered manager should encourage the person to participate in additional regular activities. The person should be encouraged if possible to develop appropriate skills to do so e.g. travel skills. There have been no regulatory breaches and this is given as a recommendation. Service users said they have appropriate opportunities to maintain links with their families and friends. Visiting arrangements are appropriate. The inspector shared a meal with service users. This was to a good standard and one of the service users was involved in the meal preparation. Appropriate records are maintained, and these demonstrate a balanced and healthy diet. Special diets are catered for. Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 12 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 standard(s) 18, 19 Service users receive personal care in a manner, which respects their respect and dignity. There are appropriate links with relevant professionals so service users physical and emotional health needs are met. EVIDENCE: Service users said they were happy with how personal care and support is provided. The inspector observed staff working with service users in an appropriate manner. Care interventions are appropriately documented in care plans. No service users have pressure sores. There have been two accident and emergency admissions since January. Support from care staff appeared to be appropriate in these instances. Accident and incident records are appropriately maintained. Staff stated links with general practitioners, and other professionals such as social workers are satisfactory. Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 13 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 standard(s) 22, 23 The registered provider has generally suitable complaints and adult protection policies, which are implemented as appropriate. However the complaints procedure needs some amendment regarding contacting the Commission for Social Care Inspection. EVIDENCE: The registered provider has developed an appropriate complaints procedure, and a user friendly version is issued to service users. However this is required to be amended to state complainants can contact the Commission for Social Care Inspection at any time, and give details how to contact the Commission. It is required this information is issued to service users and where appropriate their representatives. The registered provider has also developed a suitable adult protection policy. Newer staff complete Mencap’s ‘Protect Me’ training as part of their induction / foundation training. All staff have received a Criminal Records Bureau check, and a Protection of Vulnerable Adults check (where this is appropriate). Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 14 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 standard(s) 24-30 The home is a suitable environment for service users accommodated there. Some redecoration, and the kitchen units still need to be replaced. EVIDENCE: The building was inspected. The home offers a pleasant and homely environment for service users. The home was clean and hygienic on the day of the inspection. The kitchen units are shabby and in need of replacement. The registered manager said this work will be completed by the end of the year. The external paintwork, and some of the internal decorations are also shabby, although the registered manager said this work will be completed in the autumn. The previous requirement is subsequently renotified. Service user bedrooms are pleasantly decorated according to individual tastes. Locks are fitted to all bedroom doors, and service users are issued with a key where this is appropriate (i.e. as long as there are no health and safety risks to the user concerned). Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-36 Staff have clear roles and responsibilities to ensure the home is run effectively. Staff appear to be recruited, inducted and trained appropriately. Appropriate staffing levels are maintained. EVIDENCE: All staff are issued with a job description when they commence employment. Staff appear to have a clear understanding of their roles. The registered manager said staff are encouraged to completed National Vocational Qualifications. A minimum of one member of staff is always on duty, although rotas suggest there is usually at least one other member of staff on duty either during the day and / or in the evening. Records demonstrate staff receive generally appropriate induction and training. However some newer staff who have been in post for less than six months need to receive formal training in fire prevention, infection control and food handling. Such health and safety training should be completed within 6 months of starting employment. There is however evidence that basic instruction is given as part of staff induction. Suitable recruitment records are also maintained for example two references are maintained for new staff, also proof of their identity. Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37-43 The registered persons ensure the effective management of the home, and suitable systems are in place to evidence this. EVIDENCE: Waterloo House appears to be well managed, and staff and service users appear to receive appropriate support. The registered manager has suitable experience, knowledge and qualifications to manage the home. For example the registered manager has completed the registered manager’s award. Staff receive regular supervision, and there are staff meetings once a fortnight. Regular residents meetings are also held. Mencap has suitable quality assurance policies in place. The registered persons facilitated a survey of the views of various stakeholders regarding how the service is managed. The survey ascertained the views of service users, staff, external professionals etc. Responses were very positive. An annual development plan has been subsequently developed. Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 17 Mencap has a suitable range of policies and procedures, and suitable records are maintained. Financial records demonstrate the home is financially viable. Mencap has a suitable approach to preventing any health and safety risks. Suitable procedures are in place to test fire prevention and electrical equipment, and there is satisfactory evidence that testing is completed. For example portable appliance testing was completed in July 2005. Suitable health and safety risk assessments were completed. Appropriate checks appear to be in place regarding the prevention of Legionella. Emergency lighting should be tested more frequently than every three months in line with fire authority requirements. Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 x 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Waterloo House Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13 Requirement Where money is stored on behalf of service users, a risk assessment must be completed to ensure unreasonable restrictions are not placed on service users access to their monies The registered provider is required to be amend its complaints procedure to state complainants can contact the Commission for Social Care Inspection at any time. The policy should give details how to contact the Commission. It is required this information is issued to service users and where appropriate their representatives. The registered provider is required to expand the home’s death and dying policy to cover the care of service users who are ageing or ill, with reference to the national minimum standard. 2nd Notification The registered provider must: ·Redecorate the internal and external areas of the building to a satisfactory standard. ·Refurbish the kitchen. D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Timescale for action 1.12.05 2. 22 22 1.12.05 3. 21 12 1.12.05 4. 24 23 1.01.06 Waterloo House Version 1.40 Page 20 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 12 Good Practice Recommendations The registered manager should encourage one service user to participate in additional regular activities, and develop if possible, appropriate skills to do so e.g. travel skills. Waterloo House D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 D52-D04 S9135 Waterloo House V238981 050905 Stage 4.doc Version 1.40 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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