Inspection on 04/07/07 for Waverley House

This inspection was carried out on 4th July 2007.

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 16/05/06

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 Unannounced Inspection 4th July 2007 10:15 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.V338728.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. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 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 (30), 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 (1) Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 30 service users to include:* Up to 30 service users in the category of DE(E) (Dementia over the age of 65 years) * 1 named 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 years) 2. Staffing must be provided to meet the dependency needs of service users at all times and will comply with any guidance which may be issued through the Commission for Social Care Inspection 16th April 2007 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 also a choice of lounges and communal space for residents to relax in. There are well maintained gardens to front and rear, the latter being a secure area with patio tables and chairs. The fees range from £326 to £460 per week. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit took place on 4th July 2007 and took five hours. It was carried out by three regulatory inspectors, one of whom was a pharmacist inspector. The visit was just one part of the inspection. The home was not informed of the date the visit was to take place, but a few weeks prior to the visit the manager was asked to complete a questionnaire to provide the inspector with some information about the service. Questionnaires were also sent out to health and social care professionals to help the inspector find out what they think of the home. During the visit the inspectors spoke with staff, residents and visitors. They toured the premises and looked at various records held by the home. One inspector used the Short Observational Framework for Inspection (SOFI) methodology, which involved spending two hours observing four of the residents. Note was taken of their state of wellbeing, whether they were taking part in any activity or interaction with others, and the quality of their interactions with staff. The last key inspection was carried out in May 2006. A pharmacist inspector visited the home in June 2006 to look at the arrangements for medicines in the home. The home was not complying with the regulations in relation to medicines and several requirements were made. The pharmacist visited again in July 2006 and although not all the requirements had been met, there had been a marked improvement. The pharmacist visited again in April 2007 and found that standards in relation to medicines had deteriorated since her last visit. The registered provider was requested to attend a meeting with the Commission in May 2007. At the meeting she was requested to submit an improvement plan as to how she would address the outstanding requirements. This was received in May 2007 and a warning letter was issued in June 2007 that stated that if, on the next key inspection, compliance was not achieved, enforcement action would be taken. At this key inspection compliance had not been achieved. At the time of the inspection the registered provider and manager was on holiday. General feedback was given to her on 12th July, and more detailed feedback in relation to medicines on 24th July. What the service does well: Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 6 Residents are treated with respect. They are encouraged to maintain contact with family and friends and there is a system in place to seek the views of residents and relatives. Any concerns are listened to and acted upon. Residents are offered a wholesome and balanced diet with plenty of choice. Safeguards are in place to protect any residents’ monies handed in for safekeeping. What has improved since the last inspection? What they could do better: Residents must be assessed before admission to ensure the home can meet their needs. They must have a written care plan in place to provide detailed instructions for staff on what action they need to take to ensure all residents’ needs are met, including health and social care needs. Staff must administer and record medicines correctly to ensure that residents are not at risk of being given the wrong medication or missing prescribed medication. Residents must be consulted about the range of recreational activities they would like to participate in and a programme of activities must be drawn up to fulfil their recreational needs. Care staffing levels must be maintained at the weekend and staff training must improve to ensure that residents’ needs can be met. Recruitment procedures must be improved so that residents are protected from harm. A self-monitoring system must be implemented to ensure that the home complies with regulations and does not put residents at risk. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 7 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. Waverley House DS0000026997.V338728.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 Waverley House DS0000026997.V338728.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. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents needs are assessed before being admitted to the home, but care staff do not have access to this information to ensure that they are aware of their needs. EVIDENCE: The care files of four residents were looked at. Only one contained an assessment of the person’s needs, however this was not signed or dated. A separate folder contained copies of the social worker assessment for three of these people, but no assessment was found for the fourth person, who had been admitted for a respite stay. There was evidence from the daily notes that the respite stay had not been straightforward. The person had three falls during the stay and was reported to have ‘attacked’ a member of staff. An entry made in the daily notes reported that this person ‘needs nursing care’. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 10 There was no evidence available to show that these residents had been assessed by anyone from the home before they were admitted, however the inspectors were told that senior staff did go out to assess new residents. Following the inspection, the registered provider faxed copies of assessment documents for the other three residents. One of them was unsigned and undated. The staff on duty on the day of inspection were not aware of them. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is not based on their individual needs. Residents are at risk of harm because staff do not take care to be sure that medicines are given and recorded correctly. EVIDENCE: Four care plans were looked at and the overall standard was poor. The first resident had been admitted in February 2007. There was no assessment of her needs and no plan for how her needs should be met. This lady was very agitated and disturbed and appeared to be in some pain. On the day of the inspection she was being assessed by a psychiatric nurse to determine whether she needed nursing care. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 12 The second resident had lived at the home since 2004. A care plan had been written for her on 1st January 2007 but had not been reviewed since. Only one entry had been made in the care plan by her key worker which was on 30th January 2007. There was no record of her joining in any social activities. There was a care plan for personal hygiene, however daily records said that she was independent for daily hygiene. There was a care plan for ‘confusion’ which instructed staff to ‘monitor the effect of medication’, however it was not clear what this meant and there was no evidence that this had been done. This person’s most important need appeared to be an eye condition but it was not recorded as a need in her care plan and there were no instructions for staff about how to care for her eye condition. This had been raised at the last key inspection in May 2006 and a requirement was made. None of the staff on duty knew how to care for this resident’s eyes and said it was the responsibility of the duty managers. Neither of the duty managers were on duty that day. The third person was a new resident and there was no information at all to tell staff about her needs. The fourth person had been admitted to the home for a respite stay on 20th June 2007. There was no assessment of his needs and no plan for how his needs should be met. Four residents were observed in the middle lounge for two hours. One of the residents slept throughout the two hour observation. A second person was very disturbed and was constantly shouting and swearing which caused distress to other residents in the lounge. Staff who came into the lounge treated her with kindness and dignity although no-one spent any time with her. After an hour staff were prompted by a visiting community psychiatric nurse to move the lady into another room. The third was a new resident who had only been admitted to the home the day before. She was sitting directly next to the resident who was very disturbed and this was clearly causing her distress. She had very few interactions with staff and looked somewhat ‘lost’. She eventually fell asleep. The fourth person was well-motivated and enjoyed conversations with other residents and staff. Staff only came into the lounge when they had a task to perform, for example clearing away cups or taking someone to the toilet. Only one member of staff came into the lounge to spend time talking to residents and this was very positive. It transpired that she was an agency worker. 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 residents confirmed that staff treated them with respect and always knocked before entering their room. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 13 A CSCI pharmacist inspected the medicines to see whether they were being managed better. Requirements made in June 2006 had so far not been completely met. An improvement plan had been submitted by the home owner in May 2007. When the inspectors arrived they found that there were no staff on duty that were able to give residents their medicines. Senior care staff had come in early morning, on their day off, to give the morning doses. Inspectors were concerned that if there was a sudden need for painkillers or a dose of angina spray nobody was available that could safely help. A member of care staff had a bunch of medicine keys but said she would not know what to do if a medicine was needed. This is a serious breach of the home’s duty of care to the residents. All the keys to the metal cupboard containing controlled drugs were off the premises with senior staff. The medicine room floor was sticky and there was a box of feeds on it that had not been put away. The date expired medicines, found at the last inspection, had gone and the medicines were tidier. There was only a bottle of glycerine with the expiry date damaged on the label. There were a number of creams on the shelf, dispensed for residents in 2006, that were full or nearly full, that were no longer included in the residents’ records. There were also some barrier creams and antiseptic cream with no names on to show to whom they belonged. There was a blood pressure machine and a resident’s specimen containers in the medicine trolley, that would be better stored elsewhere. Staff could not find up to date written medicine procedures. One resident, as suggested at the last inspection, had a record of the type and dose of insulin given by the district nurse to help staff know the resident’s needs. Other medicine records were very poor. Fifteen unexplained gaps were found in the records of giving medicines. Four medicines, where the resident could have a varying dose according to need, had no record of the dose given. One resident had a new handwritten record but no records of medicines received were made. There were eight instances where the medicine records for June had not been accurately carried over to the July record resulting in the medicine not being given or the wrong dose being given. Ten residents had no medicine record sheet to record doses given after 1st July 2007 and staff had written notes on the back of the June record, only recording all medicines given. It is important for each dose to be recorded individually to be sure that residents had correct doses of all their medicines. One resident, prescribed a medicine every seventy-two hours, had been given it a day late at every dose and another resident had been recorded as having theirs more often than prescribed but there was no record to explain why. Another resident was being given a medicine at night but there were no directions included from the pharmacy or evidence that staff had checked this. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 14 Controlled drug records were not clear or made to a satisfactory standard. Overall, sufficient care is not taken to give residents their medicines correctly and to ensure records are made to a satisfactory standard. Residents are at risk as it is not possible from many of the records to find out what medicines they have been given. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents receive a nourishing diet. They are able to maintain contact with family and friends but have little stimulation in the way of recreational activities. EVIDENCE: There was very little going on in the way of social activities. The home no longer employed an activity organiser and the level of activities had declined. Two relatives had commented that there was a lack of activities and residents were bored. A senior carer on duty said that they try to do some activities in the afternoon, such as sing-a-longs and quizzes. On the afternoon of the inspection residents in the middle lounge were being encouraged to throw bean bags at a target. The administrator said that sometimes staff take residents out for a walk if the weather is fine and musical entertainers visit the home every six weeks. There had been no trips out from the home for nine months. The home owner had identified this as an area that needed improvement in the self assessment she had completed before the inspection. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 16 There is open visiting to the home. Three 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, if the weather was fine. Residents and relatives are informed of how to contact an advocate to act in the best interests of a resident, if this service is necessary. Residents are also able to bring personal possessions and small items of furniture into the home with them, to make them feel more at home. 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. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. 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. 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 six complaints since the last inspection. This was an increase on the previous year, when there had been none. Four of the complaints related to personal care. In response the home owner had employed a senior carer who was specifically charged with training and supervising all the care assistants in personal care, hygiene and the prevention of infection. There are satisfactory policies and procedures for abuse, adult protection and whistle blowing available to staff in the home. A recently employed member of staff confirmed that she had received training in this area on her induction. Since the last inspection the home owner had made two appropriate referrals to social services for the purpose of safeguarding residents. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. On the whole the home provides residents with a comfortable environment in which to live. EVIDENCE: A tour of the premises was carried out which included the communal areas, bathrooms and 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. The middle lounge where a lot of the residents sit in the morning is rather cramped and residents have to sit very close to one another. There are chairs against the French windows so residents cannot look out. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 19 This makes the lounge feel rather claustrophobic. Also, the television is situated in a position where several of the residents sitting in there cannot see it. Bedrooms and bathrooms were clean and well maintained. There is an ongoing programme of redecoration of bedrooms and the kitchen, dining room and laundry had been refurbished since the last key inspection. The lounges had also been redecorated and recarpeted. However, the carpet in the downstairs corridor between the dining room and the rear corridor was very badly stained. Also some of the chairs in the conservatory had grubby arms, at least two of which were smeared with a brown substance that looked like chocolate. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 20 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 poor. This judgement has been made using available evidence including a visit to this service. Some staff in the home are not sufficiently trained or skilled to meet the needs of the residents and recruitment procedures do not provide adequate safeguards for their protection. EVIDENCE: Staff rotas were reviewed. During the week, the home aims to provide six care staff in the morning, three in the afternoon with an extra general assistant from 5pm to 9pm 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. However, it was noted that care staffing levels were lower at the weekend and there was only one cleaner on duty every other weekend, with no cleaner on the weekends in-between. Care staffing levels should not be reduced at the weekend because residents’ needs remain the same. These reduced staffing levels may be a contributing factor to the declining standards of care. Also it is not acceptable to have no cleaning staff on duty for two days and may explain why some areas were less clean than on previous inspections. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 21 Following an additional visit in January 2006 a statutory requirement notice was served because the provider was failing to obtain a Criminal Records Bureau (CRB) disclosure for staff prior to employment, and several members of staff did not have one. A follow up visit was carried out in April 2006 and the provider was complying with the notice. At the inspection in May 2006 the staff personnel records were not available because the provider and administrator were on holiday. At that time only two staff had been employed since the last visit and they said that disclosures had been obtained. At this key inspection the records of five staff employed in the last year were examined. Criminal Records Bureau disclosures had been obtained for four of them after they commenced employment, and the other had a disclosure obtained by a previous employer. A satisfactory POVA First check had been received for only one of the five staff before they commenced employment. The Care Homes Regulations require that a registered provider must apply for a Criminal Records Bureau disclosure for every member of staff prior to employment, even if they have recently had one for another employer. Staff may not commence employment until the registered provider has at least received a satisfactory POVA First check from the CRB, when they may work under supervision until the full disclosure is received. Staff training files were reviewed. All staff were recorded as having completed an induction that covered the Skills for Care induction standards. Also, two relatively new staff members said they worked for a few weeks under supervision learning practical skills and getting to know the residents. Three senior staff had an NVQ Level 3 in Care and three other staff had an NVQ Level 2. Another member of staff was working toward a Level 2. According to the records, there had not been any training specific to the care of people with dementia since September 2005. Fourteen out of twenty three care staff had no record of having received this training. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 22 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, 35 & 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not have an effective quality assurance system in place to ensure that the home is run in the best interests of the residents. EVIDENCE: The registered manager is also the registered provider. She is a registered nurse with 30 years experience and holds a Certificate in Institutional Management. The registered manager conducted annual customer satisfaction surveys. Questionnaires had been sent out in the spring and the responses were available for inspection. Twelve of those completed were positive about the home, but one relative said they thought there should be more activities. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 23 Requirements made in inspection reports are not always adequately met. Even when they are addressed no self-monitoring system is put in place to make sure that they continue to be met, and the same shortfalls are identified again at future inspections. The arrangements for looking after residents’ personal allowances were reviewed and found to be adequate to keep their money safe. The pre-inspection questionnaire indicated that all equipment had been serviced and checked at the required intervals. 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 staff had attended fire drills in that time. The home has satisfactory policies and procedures for infection control. Staff confirmed that this was covered on induction and they were seen to maintain good hygiene while carrying out their duties. Only six staff had received training in moving and handling this year. None of the staff received any last year, four had received it in 2005 and three in 2004. Staff should receive annual training on moving and handling to make sure they are up to date with the safest way to move residents who have mobility problems. The rubber floor tiles in the lift from the ground floor were perishing, causing them to become raised from the lift floor. People’s feet were sticking to the rubber and they had become a trip hazard. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 24 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 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 2 STAFFING Standard No Score 27 2 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 2 Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 25 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) Timescale for action The registered person must 30/08/07 ensure that each resident has a written plan of care containing instructions on what action staff must take to address all the residents needs. (Previous timescales of 11/11/04, 31/07/05, 31/10/05, 31/07/06, 14/05/07 not met) The registered person must 31/07/07 make sure that doctor’s instructions are followed to ensure that residents’ health care needs are addressed. The registered person must 31/08/07 ensure that there is a written procedure for managing and recording medicines at Waverley House, so that staff know how to record and administer medicines safely.(Timescales of 31/07/06 and 31/05/07 not met) Requirement 2 OP8 12(1)(a) 3 OP9 13(2) Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 26 4 OP9 13(2) The registered person must 31/07/07 ensure that medicines records are accurately copied from the dispensing label, have the full information required, and that when medicines are given they are fully recorded at the time. (Timescale 31/07/06 and 30/04/07 not met) The registered person must 31/07/07 ensure that medicines are checked at least monthly, removing all items unfit for use or no longer prescribed, so that it is easier to find current medication and there is no risk of inappropriate medication being administered to residents. (Timescale 31/07/06 and 14/05/07 not met) The registered person must 31/07/07 ensure that there is a system in place to record, monitor and audit the quantities of schedule 2 and 3 controlled drugs to ensure their security. (Timescale 31/07/06 and 14/05/07 not met) The registered person must 30/09/07 assess the practice of all staff handling medicines, identify any gaps in their practice and provide training and supervision. This will ensure that staff have the skills to administer medication safely to the residents. (Timescale 31/07/06 and 31/05/07 not met) The registered person must 31/07/07 ensure that there are staff on duty at all times who are trained to give residents their medicines so that residents are not left in pain or distress. DS0000026997.V338728.R01.S.doc Version 5.2 Page 27 5 OP9 13(2) 6. OP9 13(2) 7 OP9 13(2) 8 OP9 13(2) Waverley House 9 OP9 13(2) The registered person must 31/07/07 ensure that staff not designated competent to give medicines, do not have access to medicine storage facilities so that residents are not at risk from drug errors. The registered person must 31/07/07 make arrangements to manage medicine keys so that they are not removed from the premises to ensure residents’ medicines are secure at all times. The registered person must 31/07/07 ensure that each resident has an up to date record of medicines currently prescribed at all times so that staff can be sure that they are giving the correct medicine. The registered person must 31/07/07 ensure that staff give medicines to the prescribed directions to be sure that residents have medicines safely. The registered person must 31/07/07 ensure that records of medicines received, given to residents or destroyed and those sent for disposal are made to show that residents have had their medicines safely. The registered person must 31/08/07 ensure that there is a system in place to audit medicine use and records. The system must document errors and anomalies to identify those staff needing training or supervision. 10 OP9 13(2) 11 OP9 13(2) 12 OP9 13(2) 13 OP9 13(2) 14 OP9 13(2) Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 28 15 OP12 16(2)(n) 16 OP26 23(2)(d) The registered person must 30/09/07 consult residents about their social and recreational needs and provide a programme of suitable recreational activities to fulfil their needs. The registered person must 31/08/07 improve the environment for residents by cleaning the chairs and carpet identified in the report. The registered person must 31/07/07 ensure that care staffing levels are not reduced at the weekend so that all residents’ needs can be met at all times. The registered person must not 31/07/07 employ a person to work at the care home unless they have applied for a Criminal Records Bureau disclosure and obtained a POVA First check in respect of that person. This is for the protection of the residents. The registered person must 31/12/07 ensure that all staff receive training in the care of people with dementia to ensure they know how to meet the residents’ needs. The registered person must 31/10/07 establish and maintain a system for reviewing and improving the quality of care provided at the home. The registered person must ensure that staff receive training in moving and handling and annual training updates to ensure they can move residents safely. DS0000026997.V338728.R01.S.doc 17 OP27 18(1)(a) 18 OP29 19 19 OP30 18(1)(c ) 20 OP33 24(1) 21 OP38 18(1)(c ) 31/12/07 Waverley House Version 5.2 Page 29 22 OP38 13(4)(a) The registered person must 31/08/07 replace the floor tiles in the lift from the ground floor to remove the risk of residents tripping on them. 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 OP19 Good Practice Recommendations The furniture in the middle lounge should be rearranged so that all residents sat in there can see the television and are not seated so close together. Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Waverley House DS0000026997.V338728.R01.S.doc Version 5.2 Page 31 - 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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