Inspection on 07/06/05 for Waverley House

This inspection was carried out on 7th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Waverley House 17/12/07

Waverley House 04/07/07

Waverley House 16/05/06

Waverley House 28/09/05

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 WA4 2EN Lead Inspector Gill Matthewson Announced 7 June 2005 09:30 th 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 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 F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Waverley House Address 27 Victoria Road Grappenhall Warrington WA4 2EN 01925 602453 01925 210736 Telephone number Fax number Email 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 Limited Mrs Pamela Roberts Care Home (CRH) 30 Category(ies) of Dementia - over 65 years of age (DE(E)) registration, with number Old age, not falling within any other category of places (OP) Mental Disorder, excluding learning disability or dementia - over 65 years of age (MD(E)) Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: This home is registered for a maximum of 30 service users including:Up to 15 service users in the category of DE(E) (Dementia over age of 65) Up to 12 service users in category of OP (Old age, not falling within any other category) Up to 3 service users in the category of MD(E) (Mental disorder over the age of 65) Date of last inspection 11th November 2004 Brief Description of the Service: Waverley House is a Care Home providing personal care and accommodation for up to 30 older people, fifteen of whom may have dementia and three of whom may have a mental disorder.It is situated in Grappenhall, which is a residential area on the outskirts of Warrington.The home was first registered in 1984 and is an adapted Victorian building, which has the benefits of a purpose built extension.There are 28 single rooms, 12 of which have en-suite facilities, and one double room. There are lifts to all floors. Television and telephone points are provided in all the bedrooms and service users are encouraged to bring in personal furniture and other possessions by arrangement. There is a choice of lounges and communal space for residents to relax in and all are well decorated and comfortably furnished.There are well maintained gardens to front and rear, the latter being a secure area with patio tables and chairs. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The lead inspector spent two hours planning the inspection by reviewing previous inspection reports and the service history over the last twelve months. The inspection took place over six hours and included a tour of the building, inspection of records and discussion with six service users, one relative and seven members of staff. In addition, comment cards were received from four other residents, three other relatives, a social worker and a community psychiatric nurse. No adverse comments were received. Residents said they were satisfied with the care they received in the home and the visitor said that the staff were very nice and kept her informed of everything concerning her mother. Feedback was given to the registered person immediately following the inspection. What the service does well: Adequate arrangements are in place to ensure that residents’ health care needs are met. Residents have control and choice over their activities of daily living and are encouraged to maintain contact with family and friends. A range of activities is available to provide social stimulation and meals are varied and well-balanced. Residents and relatives views are actively sought and they are able to raise concerns using the home’s complaints procedure. These are taken seriously and acted upon if necessary. The home provides a comfortable and safe environment and residents are able to personalise their rooms with some of their own belongings. Staffing levels are sufficient to meet residents’ needs. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Prospective residents are assured that the home can meet their needs prior to admission. EVIDENCE: Four resident files were examined. All contained evidence that a full needs assessment had been carried out prior to admission. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8&9 Resident care plans are not in sufficient detail to provide staff with full instructions to ensure that all residents’ personal care needs are met. Adequate arrangements are in place to ensure that residents’ health care needs are met and that they receive their prescribed medications. EVIDENCE: Four resident files were reviewed. All had plans of care in place, but detailed examination revealed that not all needs were addressed. For example, one resident had a stoma but the care plan gave no indication of the appliances used and how often it should be cleaned or changed. Another resident had lost weight and was being assisted with feeding, but there was no care plan to address this. Another resident was identified in the accident audit as having poor co-ordination and being at risk of falls, but this was not addressed in his care plan. See Requirement 1. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 10 Residents were registered with general practitioners and saw them as and when their needs determined. A GP was requested to visit during the inspection. Following the visit the resident was sent to hospital. Another resident went by ambulance for an investigation at the local hospital. Residents had access to all primary healthcare facilities in the community. The community psychiatric nurse visited the home. Evidence was seen of referrals to the continence advisor, chiropodist, optician and dentist. The home had satisfactory policies and procedures for the management of medicines and there was an up to date British National Formulary available for reference purposes. Residents had a lockable space in which to store medication if they were assessed as able to self-medicate. Records were maintained of all medicines received into the home and returned to the pharmacy. Administration records were satisfactory. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13, 14&15. Social activities provide stimulation and interest for people living in the home. Residents are able to maintain contact with family and friends and can make choices in their daily lives. Meals are nutritious and well presented, providing a balanced diet for the residents. EVIDENCE: An activity programme was displayed and contained a list of daily activities, which included singalongs, walks, games, bingo, cards, dominoes, arts and crafts, quizzes, jigsaws, reminiscence, beauty therapy and shopping trips. Residents’ care plans contained a record of activities they had participated in. Entertainers visited the home and staff members helped to arrange clothing parties and helped to organise other celebrations including birthday parties. Staff members were observed to have good liaison and communication skills with residents and visitors alike and a good knowledge and understanding of the people in their care. There was open visiting to the home but visitors were requested not to call at meal times. Visitors could see residents in the privacy of their room or use any of the lounges in the home or the garden. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 12 Residents were able to bring in small pieces of furniture to personalise their rooms, if they met the fire safety standards. Residents confirmed they were able to exercise personal control and choice in relation to their activities of daily living. 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 any special dietary requirements and accommodated any requests. Residents could take meals in their own room or in the dining room. Staff were observed offering discreet assistance to those who required it. The inspector had lunch with the residents, which consisted of a roast pork dinner and crumble and custard. Residents said they enjoyed the meal and some took up the offer of second helpings. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 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 had a satisfactory complaints procedure. Two complaints had been received since the last inspection. The complaints log showed that these had been investigated appropriately and action taken as a result was documented. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 19,21,25&26. The home provides residents with a safe and comfortable environment in which to live. EVIDENCE: A tour of the premises revealed that a programme of routine maintenance and renewal of the fabric and decoration of the premises was maintained. The home was found to be clean and tidy throughout. Residents were observed enjoying the sunshine in the back garden. There were two baths on the ground floor, a bath and a shower on the first floor and a sit in shower on the top floor. All baths had bath hoists. Twelve bedrooms had en-suite toilets and all bathrooms had toilets. In addition, there were two other toilets on the ground floor close to the day areas. Laundry, handwashing and sluicing facilities were adequate. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 15 Rooms were ventilated with windows that service users could see out of. Lighting was domestic in character. The inspector tested the hot water temperatures of baths and showers and found them to be within acceptable limits. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27&29. Staffing levels are sufficient to meet residents’ needs. However, recruitment procedures are not robust enough to provide adequate safeguards for the protection of residents. EVIDENCE: The home provided five care staff in the morning, three in the afternoon and evening and two at night. In addition, there was a manager, an administrator, a chef, a kitchen assistant, a laundry assistant, two cleaners and a handyman. This was sufficient to meet residents’ needs. Four staff files were reviewed. Two contained all the required information and documentation. Two did not have any references or a criminal records bureau disclosure, although there was evidence that these had been sent for. One had commenced work in the home in January and one in April. A requirement to obtain this information prior to employment had been made following the previous inspection in November. See Requirement 2. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35&38. Residents’ and relatives’ views on the quality of the service are sought and acted upon. Residents’ financial interests are safeguarded. Residents’ safety could be compromised by the lack of fire safety training for staff. EVIDENCE: The registered person conducted annual customer satisfaction surveys that included all stakeholders. The registered person stated that she used the surveys to identify where improvements could be made. Questionnaires had been sent out a few weeks before the inspection, but not all had been returned yet. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 18 The registered person was the appointee for three residents, one of whom was a relative. This had been a longstanding arrangement, but the registered person confirmed she would not undertake this for any other residents in the future. A bank account had been set up for these residents and individual balances were maintained. Apart from the aforementioned three, small amounts of spending money only were retained by the home. Records of residents’ monies were reviewed. All contained detailed information relating to all transactions and a running balance sheet was maintained for each person. A wallet was retained in the safe for each service user’s cash. A record was also maintained of any valuables that had been handed in for safekeeping. Staff had received training in moving and handling and residents had been assessed in relation to moving and handling requirements. Appropriate equipment was in place. Fire safety equipment had been tested and serviced at the required intervals, and a satisfactory fire risk assessment was in place. However, some staff had not received training in fire safety since September 2003. Twelve staff had received fire safety training in June 2004. The registered person said that further fire safety training had been arranged for later in the month. At the last inspection it was noted that no fire drills had been carried out at night for several years. Since then there had been a fire drill at 6.30am on 24th April and one at 1am on 31st May. The home employed four night staff, therefore one had still not attended a fire drill in years. See Requirement 3. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x 3 x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 3 x 3 x x 1 Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 20 Yes 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 15(1) Requirement Timescale for action 31.07.05 2. OP29 3. OP38 The registered person must ensure that each resident has a written plan of care containing instructions on what action staff must take to address all the residents needs. 19(1)(a-c) The registered person shall not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in paragraphs 1-7 of Schedule 2. (Timescale 11.11.04 not met.) 23(4) The registered person must (d&e) ensure that all staff, including night staff, receive fire training and attend fire drills at least twice a year. (Timescale 31.03.05 not met.) 07.06.04 07.09.05 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. Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 21 Refer to Standard Good Practice Recommendations Waverley House F51 F01 S26997 Waverley House V224195 070605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich CW9 7LT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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