Inspection on 16/05/06 for Waverley House

This inspection was carried out on 16th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Waverley House 17/12/07

Waverley House 04/07/07

Waverley House 28/09/05

Waverley House 07/06/05

Waverley House 11/11/04

Waverley House 29/07/04

Waverley House 14/03/04

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

CARE HOMES FOR OLDER PEOPLE Waverley House 27 Victoria Road Grappenhall Warrington Cheshire WA4 2EN Lead Inspector A Gillian Matthewson Key Unannounced Inspection 16th May 2006 10:00 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 Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 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. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Waverley House Address 27 Victoria Road Grappenhall Warrington Cheshire WA4 2EN 01925 602453 01925 210736 residentialpar@btconnect.com 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) PAR Residential Homes Ltd Mrs Pam Roberts Care Home 30 Category(ies) of Dementia - over 65 years of age (15), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (12) Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 30 service users including:* Up to 15 service users in the category of DE(E) (Dementia over the age of 65) * Up to 1named service user in the category of OP (Old age, not falling within any other category) * Up to 3 named service users in the category of MD(E) (Mental disorder over the age of 65) 28th September 2005 Date of last inspection Brief Description of the Service: Waverley House is a Care Home providing personal care and accommodation for up to 30 people over 65 years of age, predominantly for people with dementia. It is situated in Grappenhall, which is a residential area on the outskirts of Warrington. The home was first registered in 1984 and is an adapted Victorian building, which has the benefits of a purpose built extension. There are 28 single rooms, 12 of which have en-suite facilities, and one double room. There are lifts to all floors. Television and telephone points are provided in all the bedrooms and residents are encouraged to bring in personal furniture and other possessions by arrangement. There is a choice of lounges and communal space for residents to relax in and all are well decorated and comfortably furnished. There are well maintained gardens to front and rear, the latter being a secure area with patio tables and chairs. The fees range from £309 to £450 per week. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the inspection time was spent reviewing previous inspection reports and the service history over the last twelve months. The inspection took place over five and a half hours and included a partial tour of the building, inspection of records and discussion with three residents, five relatives and seven members of staff. Residents and relatives said they were satisfied with the care the home provides. One resident said ‘I like it here, everyone’s very nice’ and another said ‘I was dubious about coming here but I’m very pleased I did’. Feedback was given to the duty manager immediately following the inspection. What the service does well: An experienced person, who is considered approachable and competent by residents and relatives, runs the home. Residents are given sufficient information and opportunity to assess the home prior to making a choice. Adequate arrangements are in place to ensure that residents’ health care needs are met. Residents’ have control and choice over their activities of daily living and are encouraged to maintain contact with family and friends. Residents receive a wholesome and balanced diet with plenty of choice. Residents and relatives are confident that any concerns are listened to and acted upon promptly. A system is in place to regularly seek the views of residents and relatives. The home provides a comfortable and safe environment and residents are able to personalise their rooms with some of their own belongings. Staffing levels are sufficient to meet residents’ needs and there is a staff training programme in place. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 7 contacting your local CSCI office. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 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 Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5. The home does not provide intermediate care. The quality of this outcome area is good. Prospective residents are assured that the home can meet their needs prior to admission. EVIDENCE: The senior carer on duty explained the admission process. When an initial enquiry is made, a service user guide is sent out and the prospective resident and their representative are invited to come and have a look round. If, after this, they wish to reserve a place, the prospective resident will be put on the waiting list. When a vacancy becomes available, the registered manager or duty manager will carry out a full needs assessment and, if the home can meet the person’s needs, admission is arranged. Prospective residents can visit the home on more than one occasion and stay for meals if they wish to before making a decision to move in. Admission is always on a six week trial basis before a long term contact is entered into. Copies of individual contracts were available and complied with the National Minimum Standards. Three residents were case tracked and their files were examined. All contained evidence that a full needs assessment had been carried out prior to admission. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 10 The statement of purpose is displayed in the hall and there is a copy of the service user guide in every room which gives all the necessary information about the services and facilities available and the running of the home. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. The quality of this outcome area is adequate. Satisfactory arrangements are in place to ensure that residents’ health care needs are met and personal support is offered in a way that promotes residents’ privacy and dignity. Some resident care plans are not in sufficient detail to provide staff with full instructions to ensure that all residents’ personal care needs are met and some minor improvements are needed to ensure that eye drops are administered safely. EVIDENCE: Risk assessments are carried out for all residents, which included moving and handling and pressure areas. Residents are assessed in relation to their nutritional needs and weighed on a regular basis. A care plan was in place for the three residents that were case tracked, but they did not cover all the residents’ needs. For example, one resident was identified as being at risk of pressure sores, but there was no care plan in place to address this. Another resident suffered from repeated eye infections. The resident had been seen by the GP and optician, but there was no care plan detailing the instructions the GP had left for eye care. None of the care plans addressed residents’ social needs. See Requirement 1. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 12 Care plans contain evidence that residents and their representatives are consulted about the plan of care and reviews are carried out. Residents are registered with general practitioners and see them as and when their needs determine. Residents also have access to all other primary healthcare services in the community and evidence was seen of referrals to the dietitian, speech and language therapist, optician and dentist. The community psychiatric nurse visits the home on a regular basis. The arrangements for the storage of medication are satisfactory and the recording on the medication administration records is in accordance with relevant guidance. The record of signatures of those staff trained to administer medication has not been updated for two years. See Requirement 2. Also, staff are not dating bottles of eye drops when they open them. These have a shelf life of 28 days when opened and must be discarded after this time period. See Requirement 3. All residents apart from two are accommodated in single rooms and all personal care was observed to be administered in the privacy of the residents’ rooms or in the bathrooms. A privacy screen is provided in the double room. Care staff were observed to be courteous and sensitive to residents’ needs and residents confirmed that staff treated them with respect and always knocked before entering their room. Residents’ preference in relation to the gender of care givers was recorded in the care plan, for example it was recorded care plan that one resident does not like to receive care from male staff. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. The quality of this outcome area is good. Social activities provide stimulation and interest for people living in the home. Residents are able to maintain contact with family and friends and can make choices in their daily lives. Meals are nutritious and well presented, providing a balanced diet for the residents. EVIDENCE: Residents spoken with confirmed they were able to exercise personal control and choice in relation to their activities of daily living. For example, they could choose when to get up and go to bed and when they had their meals. One resident had her lunch later than the other residents during the inspection because she wanted to visit the hairdresser before lunch. An activity programme was displayed and contained a list of daily activities, which included singalongs, walks, games, bingo, cards, dominoes, arts and crafts, quizzes, jigsaws, reminiscence, beauty therapy and shopping trips. An activity organiser had been employed for two days a week and on the morning of the inspection was dancing with some residents. She is currently working with residents to write an individual book for each resident containing their memorable lifetime experiences. She said she is planning to provide some equipment for residents to enjoy in the garden in the summer, such as raised planters and a croquet set. Staff said that residents had enjoyed decorating cakes with the activity organiser the previous week. The senior carer said that Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 14 in the autumn residents had visited Llandudno for Remembrance Day, been to see Blackpool Illuminations and visited Knowsley Safari Park. There is open visiting to the home. Two visitors were present during the inspection. They said they could see residents in the privacy of their room or use any of the lounges in the home or the garden. One visitor was about to take a resident out for the afternoon and the other said that the family had chosen the home because it appeared to be very ‘family orientated’. Residents spoken with said they were happy with the quality and variety of food. Catering records inspected demonstrated there was a choice of food on the menu. The chef was aware of all residents’ likes and dislikes and spoke to all the residents in the morning to check they were happy with the menu for the day or did they want something else. Special dietary requirements, such as pureed diets, are accommodated. Residents can take meals in their own room or in the dining room. The serving of lunch was discreetly observed. Residents said they enjoyed the meal and some took up the offer of second helpings. One visitor said that he always had Sunday lunch in the home with his wife and “the food is excellent.” One member of staff was observed feeding a resident. The member of staff remained standing to the side and did not converse with the resident during the process. See Recommendation 1. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. The quality of this outcome area is good. The complaints procedure ensures that residents and relatives will know how to complain and gives confidence that their concerns will be taken seriously and acted upon if necessary, thereby protecting residents from harm. EVIDENCE: The home has a satisfactory complaints procedure, which is in the service user guide in every room. The complaints log and the pre-inspection questionnaire showed that there had been no complaints since the last inspection. A visitor said that she had no complaints and any minor concerns are always promptly addressed by the provider. There are satisfactory policies and procedures for abuse, adult protection and whistle blowing available to staff in the home. At a visit in April there was evidence that all staff had received training in the protection of vulnerable adults. A recently employed member of staff confirmed that she had received training in this area on her induction. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20 & 26. The quality of this outcome area is good. The home provides residents with a safe and comfortable environment in which to live. EVIDENCE: A partial tour of the premises was carried out which included the communal areas and four residents’ bedrooms. There is sufficient communal space that includes two lounges, a separate dining room and a conservatory on the ground floor. There are also a couple of small sitting areas on the first floor. All furniture is domestic in style and comfortable and the registered person has made every attempt to create a homely environment. Those areas seen were clean and well maintained. Residents are able to bring in small pieces of furniture to personalise their rooms, if they meet the fire safety standards. There is an ongoing programme of redecoration of bedrooms. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 17 Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. The quality of this outcome area is adequate. Staffing levels are sufficient to meet residents’ needs. Recruitment procedures and the staff training programme provide adequate safeguards for the protection of residents. EVIDENCE: Staff rotas were reviewed. The home provides five care staff in the morning, three in the afternoon and evening and two at night. In addition, there is a manager, an administrator, a chef, a kitchen assistant, a laundry assistant, two cleaners and a handyman. Staff interviewed said that any last minute shortfalls are covered by permanent staff doing extra hours or agency staff who have worked in the home before and are familiar with residents’ needs. The numbers are sufficient to meet residents’ needs. Following an additional visit in January a statutory requirement notice was served because the provider was failing to obtain a Criminal Records Bureau disclosure for staff prior to employment, and several members of staff did not have one. A follow up visit was carried out in April and the provider was complying with the notice. At this inspection the staff personnel records were not available because the provider and administrator were on holiday. Only two staff had been employed since the last visit and they confirmed that the disclosures had been obtained. This will be checked again at the next visit. The pre-inspection questionnaire indicated that 62 of staff have an NVQ Level 2 in Care. Discussions with staff and training records confirmed that Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 19 there was a good investment in training. Staff training files were reviewed. All staff attend theoretical training on Essential Skills for Health & Care on commencement of employment and a relatively new staff member said she worked for approximately four weeks on a supernumerary basis learning practical skills and getting to know the residents. Staff also received ongoing training in safe working practices and in the previous year had had training in dementia care, nutrition and Parkinson’s Disease. In the main, staff members were observed to have good liaison and communication skills with residents and visitors alike and a good knowledge and understanding of the people in their care. A visitor said that she was particularly impressed by the respect shown to residents by staff. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33 & 38. The quality in this outcome area is adequate. The management and administration of the home is based on openness and respect and there are effective quality assurance systems in place. EVIDENCE: The registered manager is also the registered provider. She is first level registered general nurse with 30 years nursing experience and holds a Certificate in Institutional Management. All relatives and staff spoken with said the registered manager was very approachable and listened to and valued their views. They said that any concerns raised were acted upon in a timely fashion. The registered person conducted annual customer satisfaction surveys. The registered person has previously stated that she uses the surveys to identify Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 21 where improvements can be made. Questionnaires had been sent out last September and the responses were available for inspection. The vast majority of comments were positive, although one or two relatives had said they thought there should be more activities and one of the lounges was a bit dark. The home now has an activity organiser and the maintenance person said that the provider had been in touch with a decorator and was planning redecoration of the lounge. It was not possible to inspect the management of residents’ monies because the provider and administrator were on holiday. However, arrangements have always been satisfactory on previous inspections. A file located on a shelf in the corridor contained copies of notifications sent to the Commission. These contained personal information about residents. See Requirement 4. Records showed that in the previous year staff had received training in health and safety, first aid and food hygiene. They had also received training in moving and handling, and residents had been assessed in relation to moving and handling requirements. Fire safety equipment had been tested and serviced at the required intervals, and a satisfactory fire risk assessment was in place. Fire safety training had been provided in the previous six months and all staff had attended fire drills in that time. The home has satisfactory policies and procedures in infection control, staff confirmed that this was covered on induction and staff were observed to maintain good hygiene while carrying out their duties. The pre-inspection questionnaire indicated that all equipment had been serviced and checked at the required intervals. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 22 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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x 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 3 18 3 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X 2 3 Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement The registered person must ensure that each resident has a written plan of care containing instructions on what action staff must take to address all the residents needs.(Timescale 31/10/05 not met) The registered person must maintain a record of the signatures of all staff who administer medication. The registered person must ensure that eye drops are dated on opening. The registered person must ensure that records relating to residents are kept securely within the home and not on a shelf in a public area. Timescale for action 31/07/06 2 OP9 13(2) 31/07/06 3 4 OP9 OP37 13(2) 17(1(b) 31/07/06 31/07/06 Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 24 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 OP10 Good Practice Recommendations Staff should sit when feeding residents that require assistance and interact with them during the meal. Waverley House DS0000026997.V289973.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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. 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