Inspection on 05/03/08 for Waverley House

This inspection was carried out on 5th March 2008.

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 15/08/06

Waverley House 03/03/06

Waverley House 18/11/05

Waverley House 24/03/05

Waverley House 16/11/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

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 Rebecca Harrison & Karen Powell Key Unannounced Inspection 5th March 2008 11:00 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.V360352.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 DS0000060780.V360352.R01.S.doc Version 5.2 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 Mrs Barbara Hadley Care Home 27 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (17) of places Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care to service users of both sexes whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 17 Dementia over 65 years of age (DE)(E) 10 The maximum number of service users to be accommodated is 27. 2. Date of last inspection 18th May 2007 Brief Description of the Service: Waverley House (Phase 1) is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of 27 people over the age of 65 to include 10 places for people with dementia. Phase 1 is the first part of a purpose built care home which opened on 24/05/07 to replace the original home transferred from Herefordshire Council to Shaw healthcare in 2004. The original home was built in the 1960’s and did not meet the National Minimum Standards for care homes or the increasing expectations of people needing to live in a care home. The home is located in Leominster, within walking distance of the town centre. Accommodation is provided over three floors providing a short stay; respite and dementia care service until Phase 2 is registered shortly. Following an increase in registered beds the service plans to provide specialist nursing care and long-stay care for older frail people to include people with dementia. The registered provider is Shaw Healthcare Ltd. The post of registered manager is currently vacant therefore the home has an acting manager in place. People who use the service and their representatives are able to gain information about this service from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on our website at www.csci.org.uk The fees charged were not available in the Service User Guide as required however all beds in Phase 1 are contracted to Herefordshire Council. This information applied at the time of the inspection and the reader may wish to obtain more up to date information direct from the care service. Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people who use this service experience adequate quality outcomes. The inspection was unannounced and took place on 5th March 2008 by two inspectors over 6 hours. A range of evidence was used to make judgements about this service to include discussions with service users, staff and the acting manager, surveys completed by staff and service users, a tour of the premises, quality assurance processes and observation of care experienced by people using the service. We also looked at a number of records to include care records for three people receiving a service, complaints and protection, staff training, recruitment and health and safety records. Prior to this inspection an Annual Quality Assurance Assessment (AQAA) document was posted to Waverley House for completion. The AQAA is a selfassessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. The acting manager completed this and some comments have been included within this inspection report. A random inspection of the service was undertaken on 18/5/07 to review the new accommodation provided by the completed Phase 1 of the redevelopment project prior to registration. Inspectors also reviewed how the imminent move was being managed and outcomes for people living at the home. What the service does well: The recreational activities programme is tailored to meet the individual needs and choices of service users. People using the service are assisted to visit local facilities and make use of the wide range of public services available. A service user spoken with stated ‘staff are excellent and offer professional care’ We received a number of surveys from staff who considered the home does the following well: ‘We look after the residents really well, residents always want to come back’ Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 6 ‘We provide a happy environment for the residents promoting their happiness and welfare’ The move from the former care home into the new purpose built home has proved very successful and the staff team have supported the people who use the service settle into their new home well. The home has satisfaction surveys in place as part of their quality assurance process and a comment seen on one completed file stated ‘As far as we are concerned it couldn’t be better, when our turn comes we would be quite happy to stay here. Everyone who is staying here seems to be very happy and contented’. What has improved since the last inspection? What they could do better: Waverley House has some areas for improvement. The acting manager appeared committed to improving shortfalls identified at the time of the inspection to include recruitment practices, record keeping, risk management and staff training. Phase 2 of the building is nearing completion and then it is envisaged that the home will provide a service for people with nursing care needs (pending registration). Staff and service users welcome the completion of the project given the ‘challenges’ that the building works have presented to people using the service, staff and visiting relatives. Since ‘Phase 1’ opened in April 2007 the service has received a number of complaints in relation to the weight of the bedroom doors, which poses difficulty when manoeuvring people who are wheelchair dependant and prevents frail people from entering/exiting their rooms safely. Although complaints have been acknowledged they remain outstanding and therefore need to be addressed at the earliest opportunity and in the best interests of service users. A number of records required by Regulation were not readily available for inspection to include recruitment records, all training records, provider reports, service user and relative meetings. Some records examined were better presented than others however it was reported that full office and Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 7 administrative facilities will be available in Phase 2 of the home therefore records will be made more easily accessible. The registered manager no longer works at the home. An acting manager is currently managing this service in addition to managing another large care home. The acting manager appears very committed to her role however discussions held and the findings of this inspection evidence that the home requires a full time manager who is responsible for no more than one registered establishment to provide clear direction and leadership. 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 DS0000060780.V360352.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 DS0000060780.V360352.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): 1 and 3 (standard 6 does not apply to this service) Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People requiring a respite or short stay service are provided with the information needed to decide whether this service will meet their needs. They have their needs assessed prior to admission to ensure the home is able to meet their individual needs and aspirations. EVIDENCE: The home has a Statement of Purpose and Service User Guide in place. The philosophy of the home is ‘To provide high quality care in a warm, safe, friendly, supportive and relaxed environment, which promotes independence, provides opportunities and maintains skills’. Due to the major rebuild of the home no new long-term places are being offered until the completion of phase 2, therefore any new admissions to the home are for short stay and respite services only. It was reported the respite Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 10 facility would no longer be available once the building work is completed and additional beds registered. The home has an admission policy and criteria in place. Records held on behalf of three people who were using the service were examined. These evidenced that prior to admission a needs assessment is undertaken to ensure the home is appropriate to meet people’s individual’s needs. A staff member spoken with had a clear understanding of the admissions process and reported that senior staff visit potential service users in their own homes to carry out assessments and that people are also welcome to visit the home to meet service users and staff. An overview assessment is also obtained by the local authority. A service user spoken with confirmed that he and his relative contributed to both his assessment and care planning process. Intermediate care is not provided therefore it was not possible to assess Key Standard 6. Waverley House DS0000060780.V360352.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 and 10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The health and personal care, which people receive, is based on their individual needs however individuals would be better protected if care plans were regularly updated and risks robustly assessed and monitored. People who use the service are safeguarded by the home’s system for handling, storing and administering medication. The principles of respect, dignity and privacy are put into practice ensuring people are treated as individuals. EVIDENCE: People receiving a service are allocated a designated key worker on admission to the home for continuity of care. Care records held on behalf of three people who were receiving a service at the time of the inspection were examined. These contained detailed information on how care is to be delivered. Two care Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 12 plans had been reviewed at the required frequency however the plan of care for a person known to the home and admitted on an emergency basis had not been reviewed and updated since 2006. Discussions held with service users indicated that they are involved in planning their care however not all care records examined had been signed or dated by people using the service. The acting manager committed to address this shortfall. Records seen evidence that daily routines are flexible in accordance with individual’s preferences such as rising and retiring to bed and detail all contact with significant others and outcomes recorded. On arrival to the home a formal review was being held to review an individual’s care placement. Assessments of risk to service users were available on the care files examined however one did not describe the assessment of the overall risk, whether this risk was acceptable and was not signed by the service user or relative. A Waterlow assessment had been completed for a further person and assessed, as high risk however there was no reference made to this in the persons care plan or preventative measures to maintain skin integrity. Records examined evidence that individual health needs are regularly monitored and kept under review and that the home arranges for health professionals to visit as required and appointments and outcomes recorded. Medication procedures appeared satisfactory at the time of the inspection. We observed a member of staff administrating medicines and she appeared confident with the procedure and reported that she has received training in the safe handling of medicines. Respecting service users’ privacy and dignity is a key principle of the homes overall philosophy and aims which states ‘The home will facilitate individuality, personal dignity and freedom of choice for every service user’. All service users looked well presented and a number of individuals made use of the visiting hairdresser who was at the home at the time of the inspection. Staff were seen to promote dignity and respect throughout the inspection and a member of staff spoken with reported that she received privacy and dignity training as part of her induction to the home. A service user spoken with stated ‘staff are excellent and offer professional care’ and he indicated that staff respect his privacy and dignity when delivering personal care. Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People staying at Waverley House are provided with imaginative and varied opportunities to develop and maintain their social and recreational interests and enabled to keep in contact with family and friends. People receive a healthy, varied diet according to their dietary requirements and choice. EVIDENCE: The home employs an Activities Organiser who works at home four days a week. Discussions with her clearly evidence that she is committed to her role and organises a range of activities to include keep fit, craft groups, raffles and draws, religious services and celebrations, trips out and holidays. Photographs of events held were displayed around the home. Library books are also delivered to the home on a regular basis and people have access to an independent advocacy service and information in relation to this was readily available. It was reported that service users interests and hobbies are Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 14 explored upon admission to the home and staff also ascertain people’s social history wherever possible. The visitor’s book evidenced that the home receives many visitors and during the inspection a number of relatives were seen visiting the home. People are provided with opportunities to access the local community as observed during the inspection and confirmed in discussions with service users and staff. Observations made evidence that staff respect the rights of people using the service, routines are flexible and people provided with choice wherever possible. Preferred terms of address were seen documented on the care files examined and staff were observed to use these during the inspection. Staff reported any mail received such as birthday cards, letters etc is delivered unopened and direct to individuals. It was reported that service users are provided with lockable storage facilities and can retain responsibility for the safekeeping of their money or the home can assist with this. As previously stated contact details of advocacy services were readily displayed around the home. The Menu on display reflected the choice of food offered on the day of inspection and appeared balanced and nutritional. Due to the building works, main meals are currently being prepared off site although breakfast and evening tea is prepared in the home. Phase 2 of the building will provide a fully equipped kitchen and catering service. Lunch was observed and the meal time was relaxed and unhurried. Service users spoken with said they enjoy the food offered. Staff were readily available to offer assistance where required and were sensitive to peoples needs, patient and helpful. Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives are able to express their concerns and have access to a complaints procedure. Procedures are in place to safeguard people using the service from potential abuse. EVIDENCE: The home has a complaints procedure in place and this is included in the homes statement of Purpose, Service User Guide and held on the complaints file. Since ‘Phase 1’ opened in April 2007 three people have made complaints in relation to the weight of the bedroom doors, which poses difficulty when manoeuvring people who are wheelchair dependant and prevents frail people from entering/exiting their rooms safely. Records evidenced that all complaints have been acknowledged. It was reported that these issues have been passed to senior managers at Head Office and raised at recent meetings however all of the complaints logged remain outstanding, which was fully acknowledged by the acting manager. No concerns or complaints have been raised with CSCI concerning this service. A service user spoken with during the inspection had an understanding of what to do if he was unhappy with the service provided. Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 16 The acting manager confirmed that no referrals under safeguarding adult procedures have been triggered since the last key inspection. Staff receive inhouse training on the Protection of Vulnerable Adults (PoVA) however the local multi-agency safeguarding adult policy and procedure was not readily available as required. Bedrails were seen in use for one individual however there was no evidence of consent therefore the acting manager was advised to address this at the earliest opportunity. Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 17 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 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment. EVIDENCE: Phase 1 is the first part of the purpose built care home, which opened on 24/05/07 to replace the original home on the same site. Phase 2 is nearing completion and will provide additional accommodation for older people with specialist needs. Phase1 has been built and equipped to a high standard with accommodation provided over three floors in three self contained units comprising bedrooms, assisted bathrooms and communal lounge/diner. The ground floor currently provides 10 beds for older frail people, the first floor provides 10 beds for people with dementia care needs and the second floor provides 7 beds for older frail people. The outside area is limited to a small Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 18 patio area in Phase 1. All bedrooms are single with full en-suite facilities and staff spoken with reported facilities and accommodation is much improved. Rooms seen were personalised, light and airy. The home has the specialist equipment and adaptations needed to meet individual service users’ needs. During the inspection domestic staff were seen working hard to keep the home clean and minimise the effect of the building work. Products hazardous to health are appropriately stored and the necessary assessments and available with evidence of review. Staff are provided with training in infection control procedures and a domestic member of staff stated ‘Cleaning is very enjoyable especially being a new building, but at times it can be hard when we are short staffed. It would be useful to have better storage facilities for cleaning products and trolleys’. The home was found very clean during this unannounced inspection and it is evident that domestic staff have worked very hard to ensure the home is kept spotless given the ongoing building works. No offensive odours were detected however on arrival to the home a strong cigarette smoke was present in the lounge on the ground floor where a number of service users were seated. It was reported that this was from the nearby designated smoke area however the room was not clearly marked and ventilation does not comply with smoking legislation. The acting manager committed to address this. Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People who use the service are supported by a committed staff team however the lack of records for the recruitment, training provision, monitoring and supervision of staff does not ensure that service users are in safe hands. EVIDENCE: Throughout the inspection staff were accessible, good listeners and communicated well with the diversity of needs of people using the service and appeared motivated and committed to their work. One service user spoken with stated ‘The staff are excellent and very professional’ We received a number of surveys from staff who considered the home does the following well: ‘Residents are well cared for and nothing is too much trouble’ ‘Staff communicate well with residents and relatives’ ‘We look after the residents really well, residents always want to come back’ ‘We provide a happy environment for the residents promoting their happiness and welfare’ Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 20 ‘Cares for residents very well. The carers are friendly and the atmosphere pleasant’ The Acting manager reported of the 25 care staff employed, 11 hold a nationally recognised care qualification known as NVQ at 2 or above. She fully acknowledged that level is below the National Minimum Standards but reported the home has had difficulty retaining staff once staff become qualified. Staffing levels and the deployment of staff was discussed with the acting manager and this reflected numbers stated in the Statement of Purpose although levels may vary according to numbers and dependency levels of people using the service. In addition to care staff the home employs an activities organiser, cooks, domestic staff and a laundry assistant. Staff spoken with considered the home has sufficient staffing to meet the needs of service users. Since the service was last inspected the provider has obtained our agreement for the centralisation of staff records to be held at their Head Office and keep a pro-forma (basic details) of staff information in the home in line with the Commissions policy and guidance. Pro-forma’s were not available on the four staff files randomly selected who have been recruited since the last inspection. It was reported that original documentation is held at the Head Office and photocopied documents sent to the home. Files examined were very disorganised, there were no staff photographs, no CRB disclosures and start dates were not readily available. Application forms reviewed on two files failed to contain a full employment history and there was no evidence that this had been examined as part of interview process. Without the agreed pro-forma it was difficult to assess the robustness of the provider’s practice in the recruitment, selection and retention of staff. The home has a staff-training matrix in place, which identifies induction and mandatory training completed, and refresher dates. Although staff spoken with reported that they receive in-house training, certificates to evidence training were not available on their Development and Training portfolio this was fully acknowledged by the acting manager. Individual training and development assessments were not available or details of specialist training to include dementia care, Mental Capacity Act etc. There was evidence that staff receive induction training to Common Induction Standards framework and this was available on three of the four staff examined. Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 21 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): 31,33,35,36,37 and 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The acting manager has an understanding of the areas in which the service needs to improve in the best interests of service users. Quality assurance requires further development to assess performance and evaluate outcomes for people using the service. Overall the premises are managed and maintained in a manner, which ensures the safety of service users and staff. Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 22 EVIDENCE: The manager who was registered in May 2007 no longer works at the home. On arrival to the home the acting manager, who has been in post since July 2007 was not available due to being seconded to manage another care home therefore she is currently managing two large establishments. We have not been notified of this arrangement and given that the role of the manager is a demanding one; with significant responsibility this should be given urgent reconsideration in consultation with us. A member of staff spoken with was very complimentary about the current acting manager but stated that the home requires a full time manager, which was fully acknowledged by the acting manager when she arrived to assist with the inspection. It was reported that the post of a nurse-qualified manager has recently been advertised in preparation of Phase 2, which will provide nursing care. The acting manager appears very committed to her role however discussions held and the findings of this inspection indicate that the home requires a full time manager who is responsible for no more than one registered establishment to provide clear direction and leadership. The provider has quality assurance and monitoring processes in place. It was reported that monthly visits as required by Regulation 26 take place however only reports up to October 2007 were readily available for inspection. Four completed relative and service user satisfaction surveys were available on file since the opening of new build and comments include ‘As far as we are concerned it couldn’t be better, when our turn comes we would be quite happy to stay here. Everyone who is staying here seems to be very happy and contented’. ‘Still the heaviness of the doors cause problems for my mum…’ Completed surveys seen indicate people see the staff as helpful and professional in their approach, people are able to discuss concerns, happy with how the home looks after personal possessions and that the environment is safe, comfortable, clean and tidy. Numerous other audits were available to include infection control, food, care planning, and the environment with positive outcomes. Guidelines for completion of internal quality audit programme were available. The management of people’s finances was discussed with the acting manager who considered procedures to be robust. Records of monies held on behalf of people were available however the acting manger was advised to ensure that there are no gaps left between entries, that double signatures are obtained for all transactions wherever possible and that the management of monies must clearly be stated in individual care plans. Secure facilities are provided for the safekeeping of money and valuables in people’s own rooms. Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 23 Staff files examined and discussions with staff evidence that staff are not receiving formal supervision at the required frequency, which was acknowledged by the acting manager at the time of the inspection. The home currently provides three small offices one on each floor where all records are held. It was reported that Phase 2 of the home would provide full office and administrative facilities together with care stations on all floors. Accessibility of records is a challenge and although staff were able to find a number of records not all required by regulation were readily available or well presented. For example the training matrix and information on staff was only available on the computer and accessible by the acting manager, which can pose problems if the acting manager is working between two establishments. Health and safety procedures appeared satisfactory at the time of the inspection however the acting manager was advised to ensure the risk assessments for safe working practices, reviewed in January 2008, must detail the actual degree of risk. An annual health and safety assessment was undertaken in November 2007 and the home awarded 91 with shortfalls identified in some mandatory training particularly in moving and handling and first aid. Monthly health and safety audits are also undertaken. Safety checks are undertaken at the required frequency and staff have access to a full range of health and safety policies and procedures. Waverley House DS0000060780.V360352.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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 2 2 3 Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 OP7 Good Practice Recommendations Care plans should be updated at the required frequency and any risks identified should be clearly assessed to ensure staff are provided with up to date information for the delivery of care and the management of risk. The provider must ensure that following our agreement for staff personnel records to be centralised, that the necessary information required to be held in the home is readily available for inspection so we can assess the robustness of the provider’s practice in the recruitment, selection and retention of staff. The current interim management arrangements should be reviewed in consultation with CSCI to ensure the home is effectively managed in the best interests of service users. Arrangements should be made to ensure that all staff receive formal supervision at the required frequency to ensure they are provided with the necessary support they need to carry out their jobs. DS0000060780.V360352.R01.S.doc Version 5.2 Page 26 2 OP29 3 4 OP31 OP36 Waverley House 5 OP37 The quality of record keeping must be improved to ensure that information required by regulation is accessible. Waverley House DS0000060780.V360352.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 DS0000060780.V360352.R01.S.doc Version 5.2 Page 28 - 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. 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