Inspection on 03/03/06 for Waverley House

This inspection was carried out on 3rd March 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

Waverley House 09/12/09

Waverley House 17/02/09

Waverley House 05/03/08

Waverley House 15/08/06

Waverley House 18/11/05

Waverley House 24/03/05

Waverley House 16/11/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Waverley House Etnam Street Leominster Herefordshire HR6 8AQ Lead Inspector Sarah das Neves Pedro Unannounced Inspection 3rd February 2006 03:00 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 DS0000060780.V282181.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 DS0000060780.V282181.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Waverley House Address Etnam Street Leominster Herefordshire HR6 8AQ 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) 01568 612126 01568 620445 Shaw healthcare Ltd Care Home 38 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (31) of places Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Recommended Conditions of Registration One named resident under the age of 65 can be resident at the Home (Ms Suzie Garman) Staff training Within two months of registration a review of staff training needs in relation to dementia care must be carried out. Training to meet these needs will be provided within three months of the assessment. Social and recreational activities A review must be carried out of the access to social and recreational activities provided by the home and shortfalls addressed within six months of registration. Manager training The manager must undertake specialist training in subjects relevant to the registration categories of Waverley House. (Condition 4 refers to Ms Jacqui Vaughan Jones). Monthly supervision The Manager must receive monthly supervision from a senior manager in the employing organisation. (Condition 5 refers to Ms Jacqui Vaughan Jones). 18th November 2005 3. 4. 5. Date of last inspection Brief Description of the Service: Waverley House is located within walking distance of Leominster town centre. The home offers residential care for up to 38 people over the age of 65. This includes 3 respite beds and a ground floor unit, Venn Moor that specialises in the care of up to 7 older people with mental health needs. New referrals are not being accepted for day care, which in the past offered 4 places. No new long-term places are being offered at present in preparation for a major rebuilding project. This was originally planned to commence in 2005 and has been postponed until April 2006. On the day of inspection, 28 people were resident in the home 7 of whom were in the Venn Moor unit. Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over four hours from afternoon to early evening. The purpose of the inspection was to review the requirements from the previous visit and to consider the new management of the home, thus it was limited in scope and it is advised that the previous report from the November inspection be read in conjunction with this one to obtain a more complete view of life at Waverley House. Comment cards were sent to residents and relatives and professional colleagues who visit the home. Comments on the service will be restricted to these; in all, eight responses were received. Some of the time was taken up in discussion about the proposed building development that has not yet been started. The date for commencement has been delayed until April. The staff have worked hard to meet the requirements set at the previous inspection with notable improvements in the required documentation. Overall this was a satisfactory inspection. What the service does well: 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 DS0000060780.V282181.R01.S.doc Version 5.1 Page 6 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 DS0000060780.V282181.R01.S.doc Version 5.1 Page 7 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 and 4 In view of the pending rebuilding the home is currently only admitting residents who have emergency or short-term needs. Trial periods and Intermediate Care are not currently offered. Service user contracts, the service user guide and statement of purpose were not examined during this inspection but will be reviewed following the rebuilding of the home. Residents who are admitted are subject to assessments by home staff; care plans are based on the social services assessment. EVIDENCE: Two care plans were selected at random, one of a long-term resident and the other of the most recent admission. Both plans included assessments that demonstrated the resident’s degree of need and the ability of the home to provide the required care. In the case of the most recent admission other professionals had been involved and their input recorded. Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 8 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 and 8 The manager is undertaking an audit of all care plans. Those seen had improved and were generally satisfactory with only minor omissions noted. Medicines were not reviewed during this inspection. EVIDENCE: Two care plans were considered in detail with two more also reviewed. The quality of the information contained in the plan had improved enormously and gave a generally accurate picture of the care required by the resident with some minor improvements required. The manager showed the inspector an audit tool that she was using to enable her to review all plans to highlight omissions and areas that required improvements. The staff at Waverley were co-operating well and significant improvements have been achieved. Care records show that General Practitioners, Community Nurses and other professionals are involved in the care of residents. Care plans were reviewed at least monthly. Issues that must be addressed are: • Service users have yet to be involved in the development of their care plans • Activity records were inadequate. One plan contained no entries after 8.3.05 Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 9 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): These standards were not assessed at this inspection but were generally satisfactory at the previous visit. The comments below refer to responses received in comment cards. The activities of records remains poor and are addressed with standard 7 EVIDENCE: Four relatives completed and returned comment cards. All confirmed that they were made welcome, that they could meet their relative in private and that they were kept informed about important matters. They were also satisfied with the overall care provided. Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 10 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 and 18 Staff have received appropriate training to ensure they understand their responsibilities and role in regard to the prevention of abuse. Comments received from relatives indicate that not all are aware of the complaints procedure. EVIDENCE: The training required has now been provided. The inspector reviewed the comments card completed by staff following recent Protection of Vulnerable Adults training which showed that members of staff from all departments had attended the training. With one exception, the comments indicated that the training had been understood and well received. The manager undertook to review the comments made by the dissatisfied staff member at her forthcoming supervision session. Recent events have confirmed that staff will act promptly and appropriately in the event that concerns are raised. Two of the four comments cards stated that relatives were unaware of the complaints procedure. This should be rectified to ensure that all resident representatives could bring matters of concern to the attention of the appropriate authority without delay. Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 11 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): These standards were not assessed at this inspection. EVIDENCE: Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 12 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 and 30 One comment card received said that there did not always appear to be sufficient numbers of staff on duty. This view was not supported by the duty rota’s provided by the home. The number of agency staff employed has been reduced. The owners have a comprehensive recruitment policy; the application of the most recent recruit was considered, and was found to be incomplete. Staff at the Home are given the opportunity to do training to develop their levels of competence in providing residents with the care they need. The computer records were not complete but other records were available to confirm that staff had attended study events. EVIDENCE: The company provides excellent recruitment and disciplinary procedures. The application of the most recent recruit was considered in detail. With the exception of questioning gaps in the applicant’s CV the procedure had been followed and was a marked improvement on the previous inspection. Staffing levels were satisfactory for the number of residents. There were four care assistants and a Team leader, separate catering and administrative staff; the deputy Manager was in charge of the home. The manager came to the home to assist the inspector. Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 13 Vacancies have been filled and the number of agency staff employed has been reduced; the home staff take vacant shifts without working excessive hours. The deputy manager works a mixture of care and office shifts and the activities organiser is available to support residents, for example to go out shopping, if required. The manager is supernumerary. The Provider has a well-developed training programme supported and provided by senior staff. The administrator produced a computerised record of the training undertaken by staff. The ‘2’ score given to this section is attributable to the computerised records, which were inaccurate. Confirmation of staff attendance had to be sought from other sources. In addition the documentation does not require the name of the attendee to be included, this made it difficult to identify some staff. It is the aim of the home for all staff to complete the full range of training by the end of March. This includes Moving and Handling, Fire information, Health and Safety, Infection Control, Food Hygiene etc. New staff are provided with a compulsory induction programme. The deputy managers training portfolio was up to date and showed evidence that she had attended appropriate courses. These included City and Guilds NVQ level 3 and Assessors Qualifications. A staff file was inspected and found to be satisfactory. Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 14 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): 33 The management has completed an audit of the home, a copy of which has been supplied to the Commission EVIDENCE: The organisation carried out a Quality Audit in October 2005 covering all aspects of the home. This will be reviewed and the results used to inform the next inspection. Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 15 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 3 N/A N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X X Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 16 No Are there any outstanding requirements from the last inspection? 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 17 Requirement The care plans and assessments require review and updating and should reflect accurately the needs and requirements of the residents. This must include records of activities undertaken by residents. Timescale for action 28/02/06 2. OP16 22 3. OP29 19 4. OP30 19 The registered person must 28/03/06 ensure that residents and their representatives are aware of the complaints procedure The documentation pertaining to 18/03/06 the staff recruitment, supervision and training records must be completed and be available for inspection. The timescale for this requirement has been extended. The documentation pertaining to 18/03/06 the staff recruitment, supervision and training records must be completed and be available for inspection. The timescale for this requirement has been extended. Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 17 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 OP2 Good Practice Recommendations It is recommended that administrative contacts regarding service users (such as service agreements sent to relatives for signing) are recorded in their records. This assists in following things up and informs other staff that matters are being dealt with. Not reviewed during this inspection. 2. OP9 The medication policy should be checked to ensure that it has been fully customised to Waverley House. Not reviewed during this inspection. Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Hereford Office 178 Widemarsh St Hereford Herefordshire HR4 9HN 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. Extracts may not be used or reproduced without the express permission of CSCI Waverley House DS0000060780.V282181.R01.S.doc Version 5.1 Page 19 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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