Inspection on 06/06/07 for Watermoor House

This inspection was carried out on 6th June 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Watermoor House 28/08/08

Watermoor House 23/01/06

Watermoor House 11/01/05

Watermoor House 12/07/04

Watermoor House 22/01/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Watermoor House Watermoor Road Cirencester Glos GL7 1JR Lead Inspector Mrs Janice Patrick Key Unannounced Inspection 10:00 6th June 2007 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 Watermoor House DS0000016644.V331041.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. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Watermoor House Address Watermoor Road Cirencester Glos GL7 1JR 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) 01285 654864 Gloucestershire Old People`s Housing Society Limited Mrs Barbara Diane Talbot Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 Brief Description of the Service: This care home is situated close to Cirencester Town centre and therefore is on the main bus route. The home offers personal care to predominantly older people. Communal rooms are large and airy and there is a separate dining room. Private bedrooms are for single occupancy and all have varying ensuite facilities. The majority of residents furnish their bedrooms with all of their own furniture, however if this is not possible the home will provide this. There are ample communal toilets and bathrooms most of which can provide assisted bathing. Bedrooms are on two floors, which are accessed by a passenger lift. The building is set back off the road with ample parking space and to the rear of the property there is a large enclosed garden. Alongside the property is a public park, which can be accessed from the home’s front garden. The home’s current fees from April 2007 are £368.00 per week. Extras such as Chiropody, Hairdressing and Papers/Magazines are not included. The previous inspection report produced by the Commission for Social Care Inspection (CSCI) is not currently displayed but is available on request. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on one day, by one inspector between the hours of 10am and 8pm. Prior to the Inspector’s visit questionnaires were sent to residents, their relatives and to care staff to seek their views of the services provided. These views and comments have contributed to this report. As part of the inspection process a selection of care records were read and compared with the care that was actually being delivered. This included an inspection of the home’s medication system and other health related practices. Residents’ ability to make choices, have their preferences met and have their privacy and dignity protected was also explored. Arrangements for the protection of vulnerable adults and complaints were inspected. A tour of the environment was made and systems and records relating to its maintenance and safety were inspected. All aspects of staffing the home were inspected and included the inspection of staff rosters, recruitment and training records. Arrangements for general management and administration of the home were also inspected. Any past requirements made by the Commission and by other visiting agencies were inspected for compliance. What the service does well: When residents move into the home they are given a lot of support to help them settle in. If residents’ healthcare needs increase, because the home only provides personal care, it will work closely with external healthcare professionals to enable the person to remain in the home for as long as possible. Residents’ privacy is respected and their dignity is upheld. Residents are able to make day-to-day choices and their preferences are respected. The environment is immaculately maintained and cleaned. The home is managed in a manner that has the residents’ best interest at heart. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The pre admission assessment is not being recorded adequately enough and therefore the home cannot demonstrate that it is carrying out a comprehensive assessment of needs prior to someone’s admission to the home. Some care plans still need to be more specific in the guidance they are giving to staff on how to meet a resident’s needs. Audits carried out on the medication system should be documented and should be carried out monthly so that any shortfalls in the administration of medicines or the system as a whole can be identified immediately. Include awareness in safeguarding adults in a staff member’s induction training and ensure all staff receive training on the subject to increase the protection offered to those living in the home. Ensure that during the recruitment process any gaps in employment are explored and the reasons for this recorded, again to offer more robust protection to those living in the home. The home would benefit from registering with Skills for Care and getting advice on the ‘common induction standards’ in order to improve the induction training Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 7 provided. This would improve the knowledge base for new staff so that they can carry their tasks out safely. Record staffs’ individual or group supervision sessions in order to demonstrate that staff are receiving adequate supervision. 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. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 8 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 Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 9 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): 3&6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can be sure that they will either have an opportunity to visit the home and discuss their needs or be visited by a member of the home’s staff to discuss these prior to moving into the home. However, arrangements within the home for recording this information are not robust enough and leave the home unable to demonstrate that they are completing the necessary process. EVIDENCE: Although this outcome has been assessed as adequate there are shortfalls that must be addressed. The pre admission assessment process for three residents was inspected. One assessment demonstrated that a member of the staff had been to the resident’s own home to assess her needs prior to admission. Basic needs were identified briefly. There was no date on this document however. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 10 In the second case, this had been carried out whilst the person was in hospital and very little of the information gathered had been recorded by the home. The home did receive a ‘care plan of needs’ from the local funding authority two weeks prior to the person’s admission. In the third example there was no pre admission assessment completed. Although staff informed the Inspector that they are assessing people’s needs before admission, they are not adequately documenting this information. This is not allowing the home to demonstrate that its pre admission process is robust and comprehensive. This shortfall has the potential for important information to be forgotten, not passed onto other staff and ultimately not planned for. The other reason for ensuring that this process is robust is because people coming into care are doing so with increased needs. The Commission’s surveys received back from staff, demonstrate that they are identifying a change in the level of residents’ needs and the senior staff must be sure that they are only admitting people with needs that the staff are able to cope with. One resident did confirm that she had visited the home prior to moving in and that the staff had been very helpful in helping her to settle. She also felt that they were continuing to be supportive. This home does not provide designated rehabilitation care. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 11 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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in this home are able to make choices about their care and have their right to privacy concerning this upheld, however shortfalls in care planning could lead to some residents needs not being met. A shortfall in medication practice has compromised a resident’s healthcare. EVIDENCE: A proportional view has been adopted in assessing this outcome and the shortfalls evidenced must be addressed. Care plans for the same residents as above were read in detail, including some additional assessments. There is definitely an improvement in the content of many of the care plans but there are still shortfalls. A more robust audit would highlight specific weaknesses. Several of the care plans were very individual to the resident (person centred) but others were not and did not give enough information about ‘how’ to meet a Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 12 specific need. Words such as ‘needs coaxing’ gives a flavour of what may be needed but does not offer the staff any specific guidance. One fairly independent resident and a person who wished to remain in control of her care was asked if staff had discussed with her how they may meet her specific needs. The resident said they had not but she did feel they were looking after her well. In the case of a resident exhibiting challenging behaviour, staff could describe what they did in various situations and clearly some staff had devised better ways of dealing with the behaviour than others. The care plan was not giving staff specific guidance on this, which would aid continuity in their approach. Another example demonstrated that although a basic care plan had been devised for bathing and was very ‘person centred’, there were no care plans for this resident’s joint pain and how this affected her mobility, which was a real problem for the actual person. If the pre admission assessment process had been more robust this may have identified this particular need and again if the care planning had been carried out with the resident herself, this would have been another opportunity for this to be discussed. Although the above shows shortfalls in meeting the Care Home Regulations 2001 there are however, many comments within the resident and relatives surveys that were returned to the Commission indicating that the people living in this home are very happy with the care they are receiving. The care records demonstrated that several external healthcare professionals are involved in meeting the residents’ healthcare needs. These include the Psychiatric Consultant, Community Nurse, Continence Advisor, Chiropodist and Optician. In one case this is enabling one resident to remain within the home where normally this person’s needs would be beyond what the staff can manage. The Registered Manager, in this case, is fully aware of the home’s limitations within its registration and her staffs’ abilities and for the time being is keen to support the resident and family for as long as is possible. One member of staff takes responsibility for organising the ordering of medication and the disposal of excessive stock. This person also ensures all records are satisfactorily completed. Residents are supported to safely self medicate for as long as they are able to do so. The home will arrange with the supplying pharmacy for some residents’ medication to be dispensed into different containers designed to help with this if needed. An inconsistency in the recording of one resident’s medication in relation to the actual stock left, indicated that the resident had not received the prescribed dose of medication, although it had been signed as so. This was only evident in one resident’s case and has been discussed with the staff team as a serious shortfall in meeting this particular resident’s healthcare needs. A proportional Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 13 view has been taken in relation to how safe the rest of the medication system is. The Inspector is confident that the Registered Manager will deal with this robustly. Consideration should be given to the individual staff responsible to be supervised and for some this may mean further training in the safe administration of medications. Consideration should also be given to a more comprehensive auditing of the stock and administration records, which was also discussed with the member of staff that takes the lead on medication within the home. The Inspector did not observe or was informed by residents of any situation or practice that compromised residents’ privacy or dignity. In fact the home appears to run in a manner that very much indicates that the residents’ privacy and dignity is at the core of the homes values. There are examples of residents being in control of their own doctor appointments and collecting their own medication. Staff do admit that problems can arise later when a resident’s health starts to deteriorate and they require more support in this area and staff are unaware of what the actual healthcare problem is. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 14 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 & 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to support the people living in this home to achieve a good quality of life and to try and match residents’ personal expectations. EVIDENCE: A high number of the residents living in this home are able to attend the activities provided. Some are also able to partake in a social life outside of the home with friends and family. The home aims to support residents to remain independent for as long as possible. One relative commented in their survey returned to the Commission: “ our relative is independent with her own telephone and internet access”. The resident paid for this to be installed but was given help by staff to organise it. Social outings are organised by the home but the Registered Manager explained that the home’s current mini bus has two steps up, making it difficult to access by those with reduced mobility. She explained that it has been recognised that many longstanding residents are naturally becoming frailer, so separate arrangements are being made in these cases, to provide more appropriate transport to enable summer trips out. There was only one Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 15 comment from a service user who felt there could be more outings for those unable to do this independently. The home also provides regular transport into the local town for those who wish to go shopping. Family and visitors are made very welcome and clearly form an integral part of many residents’ lives. One resident confirmed that she goes out for lunches with a friend and attends the local church. This resident joined in the home’s communion service on the day of this inspection and a quiz held in the main lounge. Another resident was heard organising tea for her visitors, who she was planning to entertain in her very comfortable ‘bed-sit style’ room. Another resident prefers to sit in a quieter area of the home and said she likes to go for a walk around the garden. This resident showed the Inspector a pendant alarm she wears. She said ‘ I am allowed into the garden if I wear this’. This is one way that residents can have their wishes and choices met but with a safeguard in place if in the event of a fall. One resident said she likes to keep ‘herself to herself’. Another said she likes her own company but is enjoying knowing that there are other people around if she wants to have a chat. This resident admitted that when she was in her own home there were times when she felt lonely. Another resident was observed getting a lot of reassurance from the staff during a period of feeling very anxious. Staff explained that this resident gets like this when she is tired and that morning she had been out to a club she regularly attends. . One resident who has visual impairment said she very much likes living in the home but does get lonely. She receives visits from family but wished the staff had more time to chat, although she said that a member of staff has taken her shopping. Another visually impaired resident attends a local club for people with the same disability. All residents spoken to agree that the food provided is usually of a good standard and plentiful. There is a choice each day and individual alternatives can also be arranged. Special diets can also be accommodated. One resident commented in her survey response to the Commission: “there is always plenty of variety” The dining room is a clean and attractive room making the dining experience a pleasant one. All staff receive training in food hygiene awareness. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 16 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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Those living in the home and visiting it are aware of how to make a complaint or raise a concern and many feel this is something they would rarely need to do. Staff awareness on the subject of adult abuse along with other arrangements help to protect the people living in this home from any form of abuse. EVIDENCE: The home has a Complaint Policy and the written procedure was on display. The home management team reported that they have not received any complaints since the last inspection (over a year ago). A complaints file is kept, the last entry being in 2005. Verbal concerns are not recorded and consideration should be given to doing this along with any action taken. The resident and relative surveys received back by the Commission indicate that everyone knew whom they would go to if they were unhappy or had a concern/complaint. Many said they could never imagine having to do this. The home has a policy on abuse and the management team confirmed that this was redistributed to staff about three months ago within a staff meeting. This is linked into other policies within the home, which help to safeguard adults such as the recruitment policy. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 17 Point 6 of the abuse policy needs to be clearer about what action is expected from staff if within an allegation of abuse or abusive situation criminal action may have occurred. This was discussed with the management staff at the time of this inspection. The majority of the care staff have received training in the processes of safeguarding adults. Six care staff missed this training for one reason or another and must be provided with this in the near future, this was explained to the senior management staff at the time of this inspection. Consideration should be given to providing the same level of training to any other staff that work in the home apart from care staff. Although a requirement in the last inspection report required all staff to have received training on this subject the Inspector has been informed that all staff were recently given a copy of the home’s policy and procedures on adult protection and that the topic was discussed within a staff meeting. She is therefore reassured that all staff have an awareness of the procedures in the event of an allegation of abuse or if they witness abuse so this requirement has not been repeated within this report. Awareness in safeguarding adults is not yet delivered to staff within their induction and consideration should be given to including this as a mandatory subject within a person’s induction period (see outcome for Staffing). Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 18 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 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from living in a home that is well maintained and which is kept clean and safe. EVIDENCE: This care home has a rolling programme of maintenance, refurbishment and decorating and is maintained to a very high standard. Refurbishment of the main hall area was almost completed at the time of this inspection and as part of this upgrade handrails had been added to one part of the staircase and the stair lift extended. These actions were taken after the home recognised that residents’ mobility needs are increasing. This was also carried out in conjunction with feedback from residents. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 19 The home does have Close Circuit Television (CCTV) but the one camera is purely used to monitor those entering the home. The home is kept very clean and arrangements are in place to support good infection control. Staff wear protective clothing during the serving of food and during some care practices and senior staff are aware of where to get further advice on infection control issues. The laundry was not viewed on this occasion but the Inspector understands that arrangements have been made to further improve infection control practice in this area in response to advice received by the local health Protection Unit. The Environmental Health Officer inspected the home in November 2006 and awarded it ‘5 Stars’ for excellent standards in food hygiene. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 20 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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can be reassured that arrangements are made to recognise their changing dependency needs, although some areas of recruitment and basic training could be more robust in order to fully protect the resident group. EVIDENCE: The Registered Manager explained that adjustments have been made in staff deployment to meet the increasing needs of some residents. This has involved making sure that most days have a day member of staff starting duty at 07.00hrs instead of at 08.00hrs. This helps to meet the needs of some residents who require the toilet or help with washing. Some senior care hours have also been extended. There remains 3 waking night staff, which the manager considers sufficient. A designated person works in the laundry during the weekdays. There are 5 cleaners working Monday to Friday and 1 at the weekend. There are also maintenance and gardening staff who carry out jobs as needed. The home exceeds the national minimum standard of 50 of care staff required to hold the National Vocational Qualification (NVQ) in care. Further NVQ training is being arranged and domestic staff are also due to commence the award in their related subject. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 21 The recruitment files of four staff were inspected. All had been appropriately cleared by the Criminal Records Bureau (CRB) and against the Protection of Vulnerable Adults (POVA) list. All had references but the robustness of these could have been improved in two cases. One ideally should have included a reference from the person’s school and another should have been their last employer. Instead character references were accepted for both. One application form only stated the ‘year’ of previous employment not specific dates, so any gaps of employment would not have been explored or identified. This has been a shortfall in the past and was discussed again at this inspection. Staff are provided with basic induction training when they commence in post. One member of staff’s induction booklet was seen. The new member of staff then works alongside senior staff until they are considered safe and competent to work alone. Certificates were seen for training in safe moving and handling in the files inspected but, although training in food hygiene was confirmed as being delivered there were no certificates present relating to this. The Inspector was informed that two of the staff had received instruction on what to do in the event of a fire and shown the fire exits, but had not yet received full fire training. A date had been booked for July of this year. Awareness in Safeguarding of Adults processes is not included in the induction training. The home should consider registration with the Skills for Care to ensure that the ‘common induction standards’ are being followed. This would include for example, training in safe guarding adults at this stage. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 22 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, 32, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from living in a home that is managed in such a manner that has their ‘best interests’ at heart. EVIDENCE: Numerous positive comments from residents and relatives have been taken into account when assessing the quality rating for this outcome the numbers of which were too many to include within this text. The current Registered Manager has managed the home for over ten years but has worked there for over twenty years. She is registered with the Commission for Social Care and Inspection (CSCI) and has completed the Registered Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 23 Managers Award (RMA). She keeps herself updated in care practices and attends all mandatory trainings. Comments within the resident surveys indicate that she is liked and respected by those living in the home. Comments such as: “ our lovely manager always has time to talk to me”, “ the manager asks me frequently if I am happy and ok”, “ I only have to talk to the manager and she sorts it out”. Residents and relatives views are asked for regarding the services and care provided at the home. These were last sought via a satisfaction survey in December 2006 and early 2007. The results of which were not yet on display in the home but were due to be. The home needs to establish a more effective quality assurance system, which encompasses robust auditing so that shortfalls in the services provided and systems can be identified and a planned approach to improvement taken. It became apparent when the care planning and medication system were inspected that the quality assurance and auditing systems were lacking. The Registered Manager acknowledged this and will seek advice on a more comprehensive quality assurance system that will suit the home. Although falls are recorded and senior members of the staff check these, again a monthly audit would help identify patterns and trends and help the home take appropriate action. This will be particularly helpful as the residents within the home become frailer, as is already beginning to happen. An announced monthly visit to the home by different members of the board of trustees helps to monitor the service and also meets with one of the regulations within the Care Home Regulations 2001. The Registered Manager’s style of management and how she communicates with residents enables her to pick up quickly on any problems or unhappiness within the home. Resident meetings are held every six weeks and are well attended. Staff meetings occur a little more frequently and a senior carers meeting was due the day after this inspection. Small amounts of residents’ monies can be kept secure if the resident requires this facility. These were not inspected on this occasion but have been in the past and the system used has always been organised and the records correct. One relative during this inspection was arranging to take his relative to the bank so she could carry out her own banking. He explained that it would be easier in many ways if he had Power of Attorney but that for the time being it was his relatives wish to carry on managing her own banking. The home’s administrator is aware of who holds Power of Attorney for which resident. The Registered Manager explained that staff are supervised adequately by working alongside a more senior member of staff if needed and by attending Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 24 individual sessions with either herself or her deputies. In these sessions staff practice and other topics are discussed. This process is not recorded however, so the home is unable to demonstrate that each member of staff receives at least 6 supervision sessions a year, either on an individual basis or as a group. Consideration should be given to recording staffs’ supervision and this should be at least six times a year. All ‘in house’ safety checks are recorded which includes a monthly health and safety check throughout the home. External companies also carry out checks and servicing on all main utilities, moving and handling equipment, lifts, fire fighting equipment and the main alarm system. Many of these records were inspected and certificates seen. Some staff have a certificates in First Aid training. The home management were aware that the Fire Risk Assessment needed updating and had already arranged for an external specialist to do this soon. The Inspector explained that the home must also have an updated policy on evacuation procedures that falls in line with current Fire Regulations. Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 25 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 X 2 Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 2 Standard OP3 OP7 Regulation 14(1) 15(1) & (2) Requirement Residents care needs must be assessed fully before their admission to the home. Following consultation with the resident care plans must be written for each identified need and must give guidance to staff on how any such need is to be met. Staff must ensure that any medicine prescribed by a General Practitioner is administered to the resident and that in the event of it not being taken by that resident a correct recording is made of why not. When recruiting staff a full employment history, together with a satisfactory written explanation of any gaps in a person’s employment, must be evidenced. A more effective quality assurance system must be devised and implemented in order to identify shortfalls in the service and to offer some structure to any improvement plans that may be needed. DS0000016644.V331041.R01.S.doc Timescale for action 30/09/07 30/09/07 3 OP9 12(1)(b) 01/09/07 4 OP29 19 Schedule 2(6) 01/09/07 5 OP33 24 31/10/07 Watermoor House Version 5.2 Page 27 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 OP9 Good Practice Recommendations Staff involved in the shortfall within this report relating to the administration of medication should be given further update training in safe administration and recording of medicines. A more comprehensive medication audit should be carried out on a regular basis and should involve the auditing of short term medications such as antibiotics to ensure that the correct number of doses are being given and to make sure the stock balance matches the signed entries on the MAR Sheet. All staff working within the home should receive training in safeguarding adults, which falls in line with the local authority’s safeguarding adults procedures and ideally the first of these should be part of a person’s induction training. The home should consider registration with the Skills for Care to ensure that their staff are receiving an induction training that meets with the national ‘common induction standards’. Staff should receive some form of supervision at least six times a year and consideration should be given to recording these in each staff file. 2 OP9 3 OP18 4 OP30 5 OP36 Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Watermoor House DS0000016644.V331041.R01.S.doc Version 5.2 Page 29 - 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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