Inspection on 27/10/06 for Waltham House

This inspection was carried out on 27th October 2006.

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

Waltham House 07/11/07

Waltham House 09/01/06

Waltham House 16/06/05

Waltham House 15/11/04

Waltham House 30/07/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Waltham House Waltham House Louth Road New Waltham Grimsby North East Lincolnsh DN36 4RY Lead Inspector Theresa Bryson Key Unannounced Inspection 27th October 2006 09:30 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 Waltham House DS0000057503.V318103.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. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waltham House Address Waltham House Louth Road New Waltham Grimsby North East Lincolnsh DN36 4RY 01472 827725 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) Infinite Care Lincs Ltd Jane Elizabeth Robinson Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: Waltham House is a large old property on the outskirts of New Waltham close to the town of Grimsby. It is set in mature gardens with car parking space to the front and side. The home is registered to provide care and support for eighteen older people over the age of sixty-five. The home has two storeys serviced by a stair lift, on the upper floor there are two sections that have further steps and therefore these areas of the home are only suitable for ambulant people. There are four bedrooms in the middle section where there are no steps to negotiate. There is one large sitting room, a dining room and a further sitting room, which leads to a conservatory. All of the communal rooms have open fires as well as central heating. There are adequate bathroom, shower and toilet areas. The home accepts service users who are privately funded and funded by surrounding local authorities starting at £329. Details about the home in the form of a service users guide and statement of purpose is always on display in the main reception area and is sent or given to each prospective service user. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day in October 2006 and was unannounced. Prior to the inspection survey forms were sent out to 16 service users out of which 7 were returned; 7 relatives of which 4 were returned; 6 health professionals of which 5 were returned; 9 staff of which 6 were returned. The inspector spoke to 3 relatives by telephone and visited 4 sets of relatives in their own homes. The inspector also looked over the event history since the last inspection including any Regulation 37 and Regulation 26 notices which had been sent. There had been no complaints or concerns raised about the home since the last inspection. On the day of the inspection 4 service users were spoken to in depth and 2 relatives and 5 members of staff. The manger accompanied the inspector for the whole of the inspection and was joined for part of the afternoon session by a Company representative to discuss future plans for the home. What the service does well: The home is always very welcoming and friendly and staff very accommodating to visitors. It has a relaxed homely feel and has been well maintained and safe to live and work in. The documentation provided by the Company ensures that all people are thoroughly assessed prior to admission to the home and adequate preparation is made to welcome them. After the initial period the staff maintain accurate records of the needs of each person and how the care has been delivered. This includes the safe administration of any drugs and how each person can fulfil their expectations and social and cultural needs. The home provides a varied and nutritious diet and people living in the home can ensure that their personal dietary needs and wishes are accommodated by the kitchen staff. Food is prepared in a clean environment. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 6 The Company ensures that staff employed at the home are safe to work with the people who live there and that they are adequately trained to do their jobs Policies and procedures are reviewed on a regular basis to ensure staff have all the necessary information to look after the people who live at the home. Supervision sessions take place to ensure staff maintain their knowledge base and any needs can be identified and rectified as soon as possible, so they work to a high standard. The environment is well maintained and all safety checks made to ensure it is a safe and clean place to live and work. The gardens are kept neat and tidy and maintained to a high standard and are easily accessed by wheelchair users. What has improved since the last inspection? What they could do better: The manager must ensure that adequate staffing levels are maintained at all time to ensure that there is sufficient staff on duty to meet the needs of each Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 7 person living in the home through a 24hour period. Failure to do so could put people living in the home at risk from needs being unmet. 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. Waltham House DS0000057503.V318103.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 Waltham House DS0000057503.V318103.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 good. Prospective service users are given the opportunity to visit prior to admission and the home uses an holistic assessment tool to enable them to commence meeting the needs of each person. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager assesses each person prior to admission to the home and often takes another staff member with her. She uses an holistic tool covering all aspects of that person’s life and current needs. This enables staff to prepare prior to a person’s admission, which ensures they can start to gain confidence in the staff looking after them. The home does not provide intermediate care and therefore Standard 6 is not applicable. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 10 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 &11 Quality in this outcome area is good. The home documents accurately all care delivered to each person using a comprehensive tool to ensure they are aware of each person’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Prior to the visit to the home survey sheets were sent to 16 service users, of which 7 were returned. 7 sent to relatives of which 4 were returned. 6 sent to health care professionals of which 5 were returned. 9 sent to staff of which 6 were returned. The inspector also spoke to 3 people on the telephone and visited 4 sets of relatives in their own homes. During the site visit 4 service user care plans were tracked in depth, 4 service users were spoken to in depth and 2 relatives. Many positive comments were given to the inspector form a variety of sources stating how kind staff were to them, that their current needs are being met and the home was a friendly, relaxed and comfortable place to live. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 11 The care plan documentation is improving all the time and shows that staff have a better awareness of service users needs and how to document accurately the care delivered to each person. There were also well-documented visits by other health care professionals and relatives and friends of each service user. The initial plan is completed by the manager and the subsequent monthly evaluations by the key workers. Each set of documentation showed that service users or their loved ones had signed to say they had seen each action plan. There was also evidence that the manager or the Responsible individual for the Company periodically checks each care plan. This ensures every one is keeping up to date with the service users needs. The deputy manager went through the drug administration records with the inspector and records appeared to be adequately kept. The homely remedies policy was being revised and this will include procedures for administering alternative therapies. At the time of the visit only one service user was using some homeopathetic medication, which the person self-administered. All staff administering medication have completed a safe handling of medicines course, and the system in place appeared safe. Service users stated how kind staff were to them, some said how staff encouraged them to be as independent as possible and one person stated. “They tell me to not rush and always have time for me”. Staff were observed through out the day assisting service users with a variety of tasks, which they performed calmly and with dignity and respect to each individual. The care of the dying person policy had been revised since the last inspection and now gives staff better instructions on how to cope with different types of situations. No Regulation 37 notices had been received by the CSCI since the last inspection, as there had been no deaths in the home. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 12 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 good. A varied programme of activities is offered to ensure that service users are able to fulfil their expectations and recreational interests on a daily basis. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plan documentation tracked showed that social and cultural needs had been identified and each person had personal profile details on file. Where a person wished to keep their previous private life confidential this was indicted on the documentation. Details of events service users take part n in recorded in the daily report sheet. The records indicated that not only group activities, but also personal one to one sessions took place with service users and there were a variety of outside sources visiting the home and events, which service users went out to in the local community. Service users themselves told the inspector how much independence they are afforded, taking in to consideration their individual medical needs. One person takes an active role in maintaining the greenhouse for example. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 13 The kitchen area was well maintained and all equipment was in working order. Informative records were kept by the head cook on temperature controls, stock audits, ordering processes and suppliers. Menus had been submitted prior to the inspection process and showed a varied diet was on offer. There had been no complaints about the food offered and several service users stated they had more than adequate portions and were offered choices each week. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 14 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 good. Service users are able to exercise their civic and legal rights and a robust system is in place to ensure they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The policies to cover protection of vulnerable adults and the home’s complaints policy remains unchanged since the last inspection. They are reviewed alongside other policies on a yearly basis. All staff had now received updated training in the protection of vulnerable adults, which has given them a sound knowledge base to identify any situation where abuse could occur. The complaints log was seen and the home had not had to deal with any complaints since the last inspection and none had been received by CSCI. Service users and relatives stated that they had every confidence that the management team would deal fairly and promptly with any concerns raised. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 15 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 good. The home was clean and tidy and records showed it was being maintained to an adequate standard and was a safe place to live and work. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager accompanied the inspector on a tour of the home, which appeared fresh and clean. The maintenance programme had previously been submitted in the home’s quality assurance audit and there was also a proposed schedule of work on display for the forth-coming month, in the manager’s office. Since the last inspection both main lounge areas had been redecorated, a new chandelier bought for one lounge and curtains were in the process of being bought and fitted. There had also been some changes in easy chairs and consideration given to colour matching with the rest of the décor. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 16 They home still uses open fires as supplementary heat in the two main lounges, but adequate precautions were in use to ensure the safety of service users and visitors. The laundry area was still well maintained and all equipment in working order. Maintenance certificates were seen. It was very clean and tidy, but because it is in an outside area all ironing is done in the utility area in the main house. Service users and relatives stated to the inspector that the clothing and linen in use was adequately maintained. The gardens had been well maintained and showed a variety of colour through flower borders and the planting of trees and shrubs. Some service users enjoyed the pond area in the summer months. All exits were hazard free. The maintenance of the home has meant the service users have a pleasant and safe environment in which to live and staff work in safe surroundings. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 17 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. The home has a robust recruitment policy and ensures staff are safe to work with service prior to employment and are trained to do their job. The amount of staff on duty needs to be reviewed to ensure there is adequate staff to meet service users needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 4 staff files were tracked in depth during the course of the inspection. All documentation appeared to be in place and adequate checks made to ensure they are safe to work with service users prior to employment. The manager had completed a training plan for each staff member for 2006/07, which indicated training already completed and what needed to be done to ensure they had the individual knowledge base to look after the service users. Apart from the mandatory training sessions such as manual` handling the home had provided training in service specific areas such as stroke care, aggression management and wound management for carers. Staff spoken to stated they had appreciated the training and found it had been useful in expanding their own horizons and future career options. Some staff were completing their last elements for NVQ level 2 care awards and this will mean the home had reached a target of 55 NVQ level trained staff. Staff appeared motivated to finish this course and had found it beneficial to their work. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 18 Staff and service users had stated that they feel at times there are insufficient staff on duty to met the needs of service users. This is particularly so of an afternoon and evening shift. On speaking to staff it appears that at those times they are also asked to complete non-caring tasks such as preparing and serving tea and sometimes some cleaning tasks. Staff were observed in the afternoon going about their work by the inspector and they looked hurried at times. The staffing rota at any time of the day or night for care staff should not include non-caring tasks such as roles in the kitchen or domestic tasks. The manager has been asked to review the care staff rota alongside using a verifiable tool to check each service users dependency level, to ensure there are sufficient staff to duty to meet everyone’s needs. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,36 & 38 Quality in this outcome area is good. Service users live in a home which is maintained to a standard to ensure they are safe and their needs are taken in to consideration at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been ensuring that she keeps herself up to date with her own training needs and has completed the Registered Manager’s Award and was awaiting her NVQ level 4 management certificate. She has recently had to take on a bigger role in the home as the Responsible individual for the Company is taking on a more arms length role, which the current management team stated was working. She is assisted by a deputy manager, who stated she has enjoying the challenge of her new role. Service users, relatives and staff sated to the inspector in written format and verbally that they have every confidence in the present team structure. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 20 Prior to the inspection the home had submitted a quality assurance tool, which was very in depth and also stated the Company’s aims for the future. This also indicated work completed with service users and other visitors to the home to ensure the Company was meeting everyone’s needs. During the course of the site visit the manger was joined by a Company representative who discussed with the inspector the Company’s views for the future as they had just been granted by the local council permission to extend the present building. It was stressed at this discussion that care and planning must ensure that all current service users are protected and their safety is maintained at all times. It was also stated that until the whole of the new extension had been completed and registered with CSCI service users could not use it. The manager was able to produce records to show that staff are adequately supervised, but they are unlikely to meet their target for this year as the system had been reviewed inline with current CSCI guidance. This has ensured that knowledge gaps in staff training can be addressed and more personal details discussed and monitored to ensure staff are continually safe to work with service users. Other records were seen such as fire safety, maintenance certificates and accident reports and audits to show that the manager is ensuring the home is safe to live and work in. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 21 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 3 X 3 Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 22 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. Standard OP27 Regulation 18.1.a. Requirement The registered person must ensure that there are sufficient staff on duty to ensure the needs of all service users can be met at all times. Timescale for action 30/01/07 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 Temperature control should be maintained in the storage areas for all medication. Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Waltham House DS0000057503.V318103.R01.S.doc Version 5.2 Page 24 - 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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