Inspection on 28/09/05 for Waverley House

This inspection was carried out on 28th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 16/05/06

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 28 TH Unannounced Inspection September 2005 10:30 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 Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 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.V251102.R01.S.doc Version 5.0 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.V251102.R01.S.doc Version 5.0 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 12 service users in the category of OP (Old age, not falling within any other category) * Up to 3 service users in the category of MD(E) (Mental disorder over the age of 65) 7th June 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 older people, fifteen of whom may have dementia and three of whom may have a mental disorder.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 service users 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. Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The lead inspector spent two hours planning the inspection by reviewing previous inspection reports and the service history over the last twelve months. The inspection took place over five hours and included a partial tour of the building, inspection of records and discussion with six service users and five members of staff. Residents said they were satisfied with the care they received in the home. One resident said it was the best thing she ever did when she moved into Waverley House. One resident said ‘I love it here, the staff are very sociable’ and another said ‘I have no grumbles, the staff and food are lovely’. Although there had been some improvement since the last inspection in care planning, three requirements remained outstanding. Feedback was given to the duty manager and administrator immediately following the inspection. What the service does well: 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’ privacy and dignity are maintained, they have control and choice over their activities of daily living and are encouraged to maintain contact with family and friends. 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.V251102.R01.S.doc Version 5.0 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 contacting your local CSCI office. Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 7 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.V251102.R01.S.doc Version 5.0 Page 8 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): 3&5 Prospective residents are assured that the home can meet their needs prior to admission. EVIDENCE: The administrator and duty manager 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. Four resident files were examined. All contained evidence that a full needs assessment had been carried out prior to admission. Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 9 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 & 10 Adequate 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. However, 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. EVIDENCE: Resident care plans were variable in quality, depending on which member of staff had completed them. Two of those examined were of a high standard and gave a full picture of all the actions staff needed to take to meet the resident’s care needs. Others provided scant information. For example, one resident had mental health needs but there was no mention of this in the care plan. Another resident was noted to have a dressing to a wound on her leg. Records of professionals’ visits indicated that this had been seen by the resident’s GP and GP liaison nurse a few weeks previously. A member of staff said that it was healing well, but there had been no mention of the wound in the records for a few weeks. The duty manager said that she and the registered manager had plans to audit the care plans in the near future. Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 10 See Requirement 1. Residents were registered with general practitioners and saw them as and when their needs determined. One resident said that she had recently seen her GP and he had referred her to a specialist. Residents also had access to all other primary healthcare facilities in the community and evidence was seen of referrals to the continence advisor, chiropodist, optician and dentist. The community psychiatric nurse visited the home on a regular basis. Residents were assessed in relation to their nutritional needs and were weighed on a regular basis. One resident spoken with had been referred to a dietician because of concerns and had subsequently gained weight. All residents apart from two were accommodated in single rooms and all personal care was administered in the privacy of the residents’ rooms or in the bathrooms. A privacy screen was provided in the double room. Privacy and dignity were included in the induction programme. 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. Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 11 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 Residents are able to maintain contact with family and friends and can make choices in their daily lives. EVIDENCE: There was open visiting to the home but visitors were requested not to call at meal times. Visitors could see residents in the privacy of their room or use any of the lounges in the home or the garden. Residents were able to bring in small pieces of furniture to personalise their rooms, if they met the fire safety standards. Residents confirmed they were able to exercise personal control and choice in relation to their activities of daily living. Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 12 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): 18 Further staff training is needed to ensure that residents are adequately protected from abuse. EVIDENCE: There were satisfactory policies and procedures for abuse, adult protection and whistle blowing available to staff in the home. Those staff who had undertaken an NVQ Level 2 in Care had received training in adult protection, but other staff had not received this training. See Requirement 2. Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 13 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): 20 & 26. 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 on the ground floor and one resident’s bedroom. There was sufficient communal space that included two lounges, a separate dining room and a conservatory on the ground floor. There were also a couple of small sitting areas on the first floor. All furniture seen was domestic in style and comfortable and the registered person had made every attempt to create a homely environment. Those areas seen were clean, free from any unpleasant odours and well maintained. Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 14 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, 29 & 30. Staffing levels are sufficient to meet residents’ needs. However, recruitment procedures and the staff training programme do not provide adequate safeguards for the protection of residents. EVIDENCE: The home provided five care staff in the morning, three in the afternoon and evening and two at night. In addition, there was a manager, an administrator, a chef, a kitchen assistant, a laundry assistant, two cleaners and a handyman. This was sufficient to meet residents’ needs. At the last two inspections it was noted that the registered provider had not obtained a Criminal Records Bureau Disclosure or reference from the last employer for some staff. The registered provider had not employed any new care staff since the last inspection. However, examination of all staff files revealed that half had no evidence of any checks with the Criminal Records Bureau. See Requirement 3. Staff training files were reviewed. All staff attended theoretical training on Essential Skills for Health & Care on commencement of employment and worked for approximately two 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 and nutrition. However, some staff had not received training in adult protection. Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 15 Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 16 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 & 38 Safe working practices are maintained but residents’ safety could be compromised by the lack of fire safety training for some staff. EVIDENCE: Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 17 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. Staff had received training in 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. Appropriate lifting equipment was in place, which had been serviced in accordance with legislation. Gas and electrical safety checks had been carried out at the required intervals. Fire safety equipment had also been tested and serviced at the required intervals, and a satisfactory fire risk assessment was in place. However, some staff had not received training in fire safety since September 2003. The home employs 32 staff. Twelve staff had received fire safety training in June 2004 and twelve in September 2005. At the inspection in November 2004, it was noted that no fire drills had been carried out at night for several years. Since then there had been a fire drill at 6.30am on 24th April and one at 1am on 31st May. The home employed four night staff, three of whom had been on duty when the fire drills were held. Therefore one had still not attended a fire drill in years. See Requirement 4. Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 18 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X 3 X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 1 Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 19 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 Timescale for action 31/10/05 2 OP18 3 OP29 4 OP38 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 31.07.05 not met) 13(6) The registered person must 31/12/05 ensure that all staff receive training in the protection of vulnerable adults. 19(1)(a-c) The registered person shall not 30/11/05 employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraphs 1-7 of Schedule 2. (Timescale 07.06.04 not met.) 23(4) The registered person must 31/12/05 (d&e) ensure that all staff, including night staff, receive fire training and attend fire drills at least twice a year (Timescale 31.03.05 not met.) Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Waverley House DS0000026997.V251102.R01.S.doc Version 5.0 Page 21 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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