Inspection on 18/03/10 for Waterhall Care Centre

This inspection was carried out on 18th March 2010.

It is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.

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

Waterhall Care Centre 10/12/08

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 28/03/2010.

Annual service review Name of Service: Waterhall Care Centre The quality rating for this care home is: The rating was made on: two star good service 1 0 1 2 2 0 0 8 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   Yes You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Jane Handscombe Date of this annual service review: 2 9 0 1 2 0 1 0 Annual Service Review Page 1 of 7 Information about the service Address of service: Fern Grove Bletchley Buckinghamshire MK2 3QH Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Name of registered manager (if applicable) Waterhall Healthcare Ltd Conditions of registration: Category(ies) : dementia old age, not falling within any other category Conditions of registration: The maximum number of service users to be accommodated is 56. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Old age, not falling within any other category (OP). Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: Manager position vacant and change in Responsible Individual 1 0 1 2 2 0 0 8 Number of places (if applicable): Under 65 Over 65 56 0 0 56 Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Annual Service Review Page 2 of 7 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Surveys returned to us by people using the service and from other people with an interest in the service. Surveys were sent out to the manager of the service to distribute; this included nine service user surveys, seven staff surveys and five health professionals surveys. The surveys were sent prior to writing this review to enable us to gain feedback from those with an interest in the service; to date we have received feedback from four service users, three staff members, one health care professional and five relatives at the time of writing this report. Those that have not yet been received at the time of writing this report will however be considered as part of our ongoing regulatory responsibilities for registered services. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. Relevant information from other organisations. What other people have told us about the service. What has this told us about the service? The home provided us with their annual quality assurance assessment (AQAA); it was clear and gave us all the information we asked for and informed us that the home was endeavoring to maintain their standard and highlighted areas in which they plan to make improvements over the next twelve months. The home inform us that they have made a number of changes as a result of listening to those who use the service which includes; acquiring a pet budgerigar , supplying book shelves and a selection of books in the quiet area of the home for users of the service to enjoy, offering music as an alternative to watching television during the day for those who prefer and improvements have been made to the newsletter to include information regarding other homes in the region. Enhancements to the environment have been made over the last 12 months to add to the comfort of those living at the home; these include decorating some of the walls in the main lounge areas and rearranging the seating on the nursing unit to encourage more interaction. Further plans are in place to continue redecorating areas of the home with service user input to provide for their comfort and enjoyment. Further improvements include introducing a shop trolley for individuals to purchase small items if required, a receptionist has been recruited to enable a full seven day cover, which resulted from feedback from visitors. The service plan to continue to make improvements over the next twelve months including making improvements to the care plans to ensure they promote person centred care, staff to be provided with one to one coaching from the recently recruited Annual Service Review Page 3 of 7 development manager to ensure that they receive appropriate support in their roles and implement best practice in all areas of care. Information provided to us in the completed AQAA informed us that equipment is being maintained such as electrical hard wiring, fire fighting equipment and the emergency call bells. We are also informed that the service has written assessments on hazardous substances and an action plan to deliver best practice in the prevention and control of infection. Forty five staff are said to have received training in the prevention and control of infection. We are also informed that the service carries out nutritional screening for each individual admitted to Waterhall Care Centre and actions are put into place where individuals are at risk of malnutrition. The service inform us that there have been twenty four complaints received during the last twelve months of which ninety percent were resolved within twenty eight days and of which one was still being dealt with when the service sent us the completed AQAA. The service informs us that they have made eight safeguarding referrals and four investigations resulted from these, we are also informed that no referrals to the Protection of Vulnerable Adults List (POVA) resulted from the investigations. The statistical information provided to us identifies that there have been no incidents, during the period of review, in which restraint has been used. The service act promptly to notify us of any allegations or incidences that place service users at risk and make the appropriate referrals to the local authority who are the lead in safeguarding vulnerable adults. Since the last key inspection a new manager has been appointed and is to register with the Commission in due course. Residents who responded to the commissions surveys sent out for this review generally expressed satisfaction with the home; all who responded inform us that there is someone available that they can speak to informally if they are not happy but one reported that they do not know how to make a formal complaint. All tell us that the home makes sure that they get the medical care that they need and that the home usually arranges activities that they can take part in if they wish. We asked if they like the meals at the home and all replied sometimes with one person adding meals could be tastier, bland at times and meat particularly joints are often quite tough.. Under what could the home do better? people commented could be cleaner - fresher smelling and seem to be short staffed staffed a lot, staff appear stressed and running about. Three members of staff returned completed surveys. All said they are sometimes given up to date information about the needs of the people they support and care for. All said that their employer had carried out checks before they started work, such as Criminal Records Bureau checks and uptake of references. Two told us that their induction mostly covered everything they needed to know about whilst one answered partly. All said that they are being given training that is relevant to their role and helps them understand and meet peoples individual needs but all said that the training does not keep them up to date with new ways of working and one said the training does not give him/her enough knowledge about health care and medication. In response to us asking does your manager give you enough support and meet you to discuss how you are working? two answered sometimes and one never although all three did say that they usually feel they have enough support, experience and knowledge to meet the different needs of those living in the home. All tell us that they know what to do if someone has concerns about the home. Under what does the home Annual Service Review Page 4 of 7 do well? staff did not add any comments but did provide comments in response to what could the home do better? which included support for the members of staff to gain more knowledge and experience that we can relate to our job maintain the right number of staff proportionate to the dependency needs of the residents so the quality of care can be given to them add more staff to the floor, especially carers to meet the dependency levels of the residents to give the quality care for residents. One informed us about concerns in relation to the laundry in which they stated some of the residents clothes are missing, concerns re this not dealt with and pass the problem onto the carers.. Five surveys were returned to us from relatives, all of who generally expressed mixed views about the home. All told us that they or their relative always or usually get enough information about the care service to help them make decisions, that they usually or always feel the service meets their relatives needs. They all told us that they are generally kept up to date with important issues affecting their relative and tell us that the home responded appropriately if they or their relative have raised concerns. In response to what does the home do well? comments included; the care is excellent with regular carers and nurses. Food is good and hot, rooms are clean and residents look clean and well cared for. Most of the carers are very kind and patient, I can honestly say both staff and management have been great in helping both myself and my mother with her decision to go into a home. I cant praise the staff enough for all that they do, Thanks to the care that my mum has received I feel it has extended her life, they all do a wonderful job ....its nice quiet and clean and the rooms are comfortable. There are lots of activities nurses/carers are wonderful, 100 I cant thank them enough and medical care, emotional care, welcoming relaxed atmosphere, a pleasant environment throughout the home. In response to what could the home do better? one said not enough staff they seem very stretched. Residents need more stimulation, with staff having more time to talk to patients. When a resident is in bed for some reason, it is lonely as the staff do not have the time to spend with individuals. Two others felt improvements could be made around the laundry distribution with one adding my one big complaint is the laundry my mother has adequate underwear and nightwear; sometimes it is three days when there are nightdresses in the drawer and very little underwear. I have been to the laundry and collected her things which are ready but nobody delivers them. The commission were also contacted by a relative of a service user, prior to this review, who informed us of concerns around the loss of washing and laundry, hygiene in relation to dirty cups in use and the lack of respect to personal belongings. One health care professional returned a survey and generally expressed positive views about the home informing us that the home usually monitors peoples social and health care needs properly, that they are reviewed and met, that they usually seek advice and act upon it to meet their needs and improve their well being. They further told us that the service always respects peoples privacy and dignity and believes that that the staff have the right skills and experience to meet individuals needs. The person informed us that the service does well in providing a rehabilitation setting to prepare temporary residents going home or to a different setting when appropriate, that they spend time with residents to ensure that they follow their wishes and they also do well in gathering committed staff to fulfill care and therapeutic functions. In response to what could the service do better? they said increase clinical time designated for treatments and interactions with rehabilitation patients in order to increase efficiency of the service (raise numbers of incoming/discharge patients as well as efficient transferring to other Annual Service Review Page 5 of 7 services e.g long term care settings, sheltered housing The information that has been provided in order to carry out this review indicates that there are areas that the registered person should look into to ensure that peoples care is fully meeting their needs. What are we going to do as a result of this annual service review? We will do a random inspection by 31st August 2010 to look at the issues raised in this review. 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