Inspection on 07/05/07 for Waverley Nursing Home

This inspection was carried out on 7th May 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 Nursing Home 08/12/08

Waverley Nursing Home 09/10/08

Waverley Nursing Home 23/03/08

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Waverley, The 14/16 Waverley Road Liverpool Merseyside L17 8UA Lead Inspector Mrs Julie Garrity Key Unannounced Inspection 11:25 8th May 2007 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, The DS0000068442.V342385.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, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waverley, The Address 14/16 Waverley Road Liverpool Merseyside L17 8UA 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) 0151 727 4224 Mr Stephen Greenmantle Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Accommodation of one named service user who is under 65 years old, within the overall total of 20. 26th February 2006 Date of last inspection Brief Description of the Service: The Waverley provides nursing care and personal care For a maximum of 20 residents. The home is a converted building on four floors, there are twp lounges one on the lower ground floor and one on the ground floor. Bedrooms are located on the ground floor, first and second floor. There are gardens at the rear that are accessible from the main building and parking to the front and the side. The Home is located in a residential part of Liverpool near to the shopping areas of Lark Lane and Sefton Park arae. There are frequent buses to this area and a train station within 15 minutes walk. Fees are charged in the home in accordance with those paid by Liverpool Social Services. Private clients fees are based on their individual assessment and the support that they need. There are several areas not covered in the fees such as hairdressing and newspapers. The home’s owner has only one home and is relatively new to owning care homes. The manager has been in post for several years. Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over a period of one day. The inspector arrived at the home at 11:25 and left at 16:55. The inspector spoke with 5 residents, 1 relative, 5 staff, the manager and the owner. During the day 50 minutes were spent observing the interactions of staff and residents over the lunchtime period. Individual residents care was looked at from admittance and during their stay in the home. The inspector completed the inspection by a site visit to The Waverley and a look at the building. Written records in the home were looked at and these included, care plans, assessments, staff files, staff training, staffing rotas, cleaning records, GP visit records, information to residents and daily record. Information supplied from the home such as a completed questionnaire, reporting of incidents and correspondence was also reviewed as part of this inspection. The inspector followed an inspection plan written before the start of the inspection to ensure that all areas identified were covered. All of the Key standards were covered in this inspection, additionally other standards identified were also reviewed at the inspection, and these are detailed in the report. Feedback was given to the manager during and at the end of the inspection. The arrangements for equality and diversity were looked at during the visit and are detailed throughout this report. Particular emphasis was placed on the methods that the home used to determine individual needs, promote independence and support residents to make informed decisions in line with their individual choices. What the service does well: The Waverley has a staff team who have worked in the home for several years and are able detail the majority of the care needs of the residents. Records such as care planning provide staff with very clear instructions as to how to support the residents to fully meet their health needs. As a small care home there is a welcoming atmosphere. All the residents spoken with were pleased with the care that they receive in the home comments such as “I’m very happy here” and “staff are lovely” were made by the residents frequently. Residents particularly enjoy the food, which they said was “tasty” and “ very nice”. Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 6 All the staff spoken with were enthusiastic and wanting to supply a good service to the residents. They demonstrated a genuinely warm and caring attitude in keeping with their roles as care staff. 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. The summary of this inspection report can be made available in other formats on request. Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 4 were assessed at this visit. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents are assessed before they move in, this is done to help the staff understand the needs of the residents and for the resident to decide if they want to live in the home. Information to residents and assessments could be improved in order that residents have a good understanding of what services the home provides. This will also mean that residents who staff have the skills to care for residents who are admitted. EVIDENCE: The manager makes sure that all residents receive an assessment before they are admitted. This is done in order that the staff can know what the needs of residents are before they move in and arrange support to meet their needs. There are several residents with psychological needs, the staff have not had training in this area. As such it will be difficult for the staff to fully support the Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 9 residents particularly when new to the home. The manager stated that plans are in place for all staff to receive training to meet the residents assessed needs. Assessments done before the resident moves in do not look at resident’s psychological needs. Full assessments need to be in place so that staff can find out and meet all the needs of residents. Staff say that they are made aware of new residents to be admitted and they are allocated to a staff member on duty that day to make sure they can be “helped to settle in”. This is good practice and helps residents to feel welcomed in the home. The information in the home has not been updated to include the changes in the owner. Two residents spoken with don’t remember if they were given any information but don’t have any now. One resident said she “thought daughter had it all, she came to look around the home for me, she liked it a lot and as it’s nearer I thought why not”. Without good clear information that explains the home to prospective residents it will be difficult for them to make a choice to decide if the home is for them. Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 10 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): Standards 7, 8, 9 and 10 were assessed at this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Medications management is not sufficient enough to make sure that all the residents get the medications that they need. The actions that staff need to take to make sure that they can meet the residents needs are well written and very clear. Staff are aware of these and make sure that they support the residents as well as they can. EVIDENCE: Six residents medications were looked at. The manager has put into place a good records system that identifies who each resident is and what medications they are to have. It also details what the side effects of each medication. This makes sure that all staff have the right information they need to give out medications safely. However the records showed that four residents had not received their medications as prescribed. Medications were not being given out Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 11 safely as one member of staff was seen to have put medications in a pot and leaving it in the medications storage to be given out later. This is unsafe practice and means that the medications are not given out as the homes own policy says they should. Not all medications could be located and a large amount of painkillers could not be found. Medications that were to be disposed of were not properly recorded and the medications due to be returned were not maintained securely. The manager put these medications is a secure place during this visit and put arrangements in place to keep them secure in the future. There is no medications audit to determine competency of staff. Staff who give out medications are nursing staff and one senior carer, none have had recent training in giving out medications. Staff need to be able to give out medications safely and assessments of competency and training in medications will enable them to do so. Residents care plans were viewed, these are kept up to date and contained clear instructions to staff as to how to care for the resident. Were a resident’s needs had been identified a plan as to how to support the resident was in place. All the plans are looked at monthly and kept up to date at all times. Staff spoken with say that they look at the care plans regularly and are asked for their point of view when they are changed. It is good practice that all the residents needs have clear advice to staff that details how to support the residents and means that all staff will be able to support the residents in the same way. Two care plans had evidence that resident or relative were involved in the plan. Daily records varied in quality with very clear details as to care that had been given to “uncomplaining”, which is a phrase that does not preserve the residents dignity or describe how they are that day. One resident has a pressure ulcer, records were in place as to what dressings needed to be done and when. However there was no clear monitoring of the wound such as wound mapping, depth, grade or photos. There were no records available that a specialist nurse had been contacted for advice and guidance. Observations during the day showed that staff did address residents by their names. Although terms of endearment were used these were intermittent and in context. Two residents were “very happy with the care” and “couldn’t want for anything more”. Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 12 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): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are keen to support the residents, however they do make decisions for residents less able to express a choice. They have little or no information on which to base resident’s choices and rely on discussions amongst themselves. The opportunity to fully explore and record each individual’s choices, preferences and daily routines has not been taken for all the residents and this will mean that not all residents’ wishes are respected or met. EVIDENCE: A menu is available that details that alternative diets are available, however the menus were only available in the kitchen and were not distributed to residents for them to see. The cook said that the previous owner set the menu. However he did try to alter it if he noted items were not getting eaten. Staff said they were sure they knew “what the residents liked”, they “have worked there for several years and were aware of the residents needs”. The menu is reviewed in a very informal way with little evidence that residents are consulted about their choices. Those that can express an opinion are Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 13 consulted with as and when. However those less able to express a choice influence the menu only on what the staff think they like. All residents said that the food was “very nice”, “tasty” and “ I really enjoy it he’s a very good cook”. Over lunchtime three residents sat in the lounge downstairs. Two carers supported these residents to eat. Initially both stood next to the residents. Both care staff then sat down at the eye level of the residents, which is a more comfortable way for staff to support residents to eat. One carer assisted two residents at once, on no occasion did she explain what the food was to the residents, nor was the resident asked what they would prefer. Both care staff spoke to each other more than they spoke to the residents. The communication with the residents did not support them to make a choice or inform them of what they were eating. The activities co-ordinator keeps records of the activities that residents have done. There are no records that detail the routines of the residents such as when they like to have a drink or eat a meal. Without this it is difficult for staff to understand residents preferences and to support these preferences. Two residents said that they were not aware of what activities were available or what choices of food there was. There are no records in the home that detail residents personal choices, preferences or their cultural needs. Restrictions such as smoking were detailed in care plans but were not always fully explained one example was two residents were restricted to 10 cigarettes a day but there was no explanation for this. The manager detailed that this was due to a lack of finances however this was not detailed in the plans or discussed with the residents. There have not been any residents or relatives meetings. Three residents were spoken with in their bedrooms, none had any stimulation in the room, no music, television, books or pictures on the wall. There were no records available in the home that stated that this was the way that the residents preferred to be. All three residents have dementia or mental health needs and find it difficult to discuss their choices with staff. The opportunity to explore this with the residents or their relatives had not been taken. Of the five residents spoken with three said that they could get up and go to bed, as they want, the others were unsure. One resident said “these girls are good, nothing is too much for them”. Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 14 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): Standards 16 and 18 were assessed at this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have the confidence to report any concerns that they may have. Policies and procedures are available in the home, however Staff need to be fully aware of how these policies work to make sure that residents are safeguarded. EVIDENCE: Training records show that not all staff have received training in safe guarding vulnerable adults. A situation with a member of night staff has been recently resolved, several staff were aware of this situation but had not reported the situation to the manager in accordance with the homes policies on raising concerns. Policies and procedures in this area have not been reviewed for three years. Two staff spoken with were able to detail what they thought should be reported to the manager. However neither knew that investigations in this area were not be investigated by the manager. Both would have started an informal investigation, speaking to other staff before they raised concerns with the manager, this action would mean that the situation could not be properly investigated. The manager detailed that he had identified in a recent situation that the night staff were also unaware of whose responsibility it was to undertake investigations. Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 15 A policy regarding complaints is available, however not all residents are aware of this. Of the three spoken with regarding this none had seen a complaints policy. All said that they had no problems but if they did they would tell the staff. There were no records regarding the concerns raised in the home by Social Services and the commission in the last 12 months. The manager did not realise that it was good practice to keep records of all concerns raised in order to monitor them. Staff said that they resolve any concerns as they arise, as there is nowhere particular for them to record concerns. They may write it in the daily records, the diary, leave a note for the manager or discuss with the nurse on duty. Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 16 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): Standards 19, 20, 21, 23, 24, 25 and 26 were assessed at this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is not maintained to a reasonable standard as a number of areas are in need of redecoration and refurbishment. Some of the bedrooms lack a personal touch that would make them appear warm and welcoming. Although clean and tidy, damaged furniture and lack of equipment that prevents the spread of infection places residents at risk. EVIDENCE: The building is on four floors, there are two lounges one on the ground floor another in the basement area next to the managers office. The downstairs lounge has dining tables in place, the upstairs lounge does not have any dining tables. All of the home certificates such as gas and electricity were up to date and maintained the safety of the building. Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 17 A number of areas of the home were looked at most were in need of redecoration or refurbishment this included, two bathrooms, the main corridors, four bedrooms, both lounges and the furniture in the main lounge on the ground floor. There is no maintenance plan that details what needs maintaining and when. There are no regular audits that determine the areas that need redecorating. Two residents said “It could do with a lick of paint” and “used to look much nicer, I’d like my bedroom a different colour and new carpets too” The home was clean and tidy and cleaning schedules were in place that prompts staff to maintain the cleanliness of the home. This was particularly applicable to the kitchen were all the equipment was very clean and well maintained. Over lunch two staff attended to three residents and supported them to eat. Neither staff member wore protective clothing such as plastic aprons that would help prevent the spread of infection. One member of staff assisted two residents at once, this is poor practice. Other areas of the home that deal with handling bodily fluids such as the laundry did not have items available that would protect the staff’s uniforms during this task and prevent them from spreading infection to the residents. Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 18 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): Standards 27, 28, 29 and 30 were assessed at this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All but one staff member have the full checks that they are suitable to work with the residents before they start working in the. The homes training has been increased and consideration has been made to training staff in meeting the specific needs of the residents. However the opportunity to determine if staff are competent has not been taken. This has lead to staff demonstrating a lack of competency in managing medications and communicating effectively with residents less able to communicate verbally. EVIDENCE: Four staffing files were viewed all staff had been checked before they started working in the home. Only one member of staff did not have two references and the manager made arrangements to obtain it during the inspection. A staff training plan was available this detailed mandatory training and when it was due. This does not detail staff training for needs of the residents such as dementia, depression, tissue viability, medications, care planning, diabetes etc. Although training is planned in these areas not all staff who need it have received it. The opportunity to determine if the training that staff have had and their skills are sufficient for them to complete their job role has not been Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 19 taken. An example of this is there is no assessment of competency for staff giving out medications. Staff observed over lunchtime had insufficient skills to communicate with residents. They have not received any training in communicating with people less able to express an opinion or dementia care training. Staff spoken with were clearly able to detail physical needs and behavioural needs of some of the residents. With regards to one resident three staff said that they found the individuals behaviour difficult to deal with a times and were unsure of how to respond. Two staff said that they found it very difficult to communicate with some of he residents. The staffing rota detailed that staffing levels altered daily with different amounts of staff available each day. There was no explanation for this other that staff shift patterns. When staff were absent or sick another member of staff was brought in most of the time but not always. No formal records of monitoring staffing levels were available. Although the manager does look at these on occasions, this is not done on a regular basis Four residents spoken with had positive comments about the staff. “they work very hard, always rushing around getting things done”, “very nice girls, look after me very well, try very hard”, “there’s plenty of staff available, I don’t often have to wait Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 20 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): Standards 31, 32, 33, 35 and 38 were assessed at this visit. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents living in the home are happy and settled. The opportunity to develop the quality of the service in the home is not in place. This has resulted in areas of the service no longer being of a good standard. The management of resident’s funds, health and safety and risk assessments needs to be improved to safeguard the residents and their rights. EVIDENCE: On previous occasions the manager gave out questionnaires to residents and their relatives to determine the quality of the service. This has not happened for sometime and residents meetings in which residents can influence the service have not taken place. Staff say that they have not had staff meetings Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 21 for several months, they were unaware of a residents meeting. No copies of any minutes existed. Staff and residents meetings support the service to understand the resident’s needs and to increase the quality of the support supplied. Policies and procedures had not been reviewed for over two years and as such many are now out of date and do not reflect the needs of the residents or changes in best practice advice. General checking by the manager on the quality of the service has also not occurred, this has resulted in poor practice being seen in the management of medications, risk assessments for residents and recording of wound care as examples. Accident records showed that four residents fell more frequently however falls risk assessments were not in place. A computer spreadsheet is used for resident’s funds. A breakdown of what each resident is entitled to is not available. The manager is not aware of who is appointee for the residents funds and therefore legally responsible. Receipts were available for spending. However were multiple items had been purchased for more than one resident it was not always possible to find out whose spending was whose. This is poor practice and means that residents may not always have their full funds available to spend. There are always some funds available for the residents as the senior member of staff can access the funds held. The readily availability of residents funds for the residents to use as they want is good practice and does not restrict their rights. Records for fire testing and general checks were all in place such as emergency lighting, fire alarms. However no records were available that staff checked that fire doors were closing properly or that the call system was working. This was done on a yearly basis. The residents spoken with said, “I like it here”, “very handy for my family”, “its okay staff are very nice” and “I’m happy”. Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 22 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 2 X 3 2 X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 2 2 x 2 2 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 x 2 x x 2 Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13 (2) Requirement Timescale for action 28/05/07 2. OP14 16 (2) (m) 3. OP16 22 (3) (4)(5) Medications must be appropriately managed to maintain the safety of the residents. Staff need to give out medications in accordance with the homes own policy and make sure that they follow the prescription given by the GP. The opportunity to explore, find 07/08/07 out and put in place actions to meet residents personal preferences and choices. This is of particular importance for residents less able to voice an opinion whose equality and diversity needs are not being explored or addressed. 07/06/07 All persons acting on behalf of a resident must be given a copy of the homes complaints procedure. A record of any complaint made, details of any investigation, action taken and outcome must be kept at the home. Outstanding date due 01/09/06 Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 24 4. OP19 23 (1) (b) The registered person must review the environment to identify all maintenance areas. A maintenance schedule as to when and how the home will address the maintenance issues must be developed. A copy of this will need to be shared with the residents and all the stakeholders in order that all are aware of how this will impact on them. A copy will also need to be sent to the Commission. Outstanding date due 01/10/06 The lack of good practice to prevent cross infection and the usage of equipment is insufficient to prevent the spread of disease. This will need to be reviewed and appropriate measures taken such as audits of environment, correct equipment, policies and procedures and staff training put into place. 21/06/07 5. OP26 13 (3) 21/06/07 6. OP27 18 (1) (c) 7. OP27 18 (1) (a) Staff training is not sufficient to 28/06/07 fully safeguard residents needs. Training that is specific to the residents needs will need to be put into place. A plan that details what each individual member of staff training needs are and how they are to be developed will need to be put into place. This will need to include all the areas identified within this report Staff competency regarding 28/06/07 medications, communicating with residents effectively and protection of vulnerable adults is not sufficient to safe guard the residents. Arrangements that review staff competency and address any concerns will need to be developed. A system that DS0000068442.V342385.R01.S.doc Version 5.2 Page 25 Waverley, The 8. OP33 24 (1) (2) (3) 9. OP35 17 (2) schedule 3 10. OP38 13 (4) (b) 11. OP38 13 (4) (a) regularly monitors staff skills and addresses any shortfalls needs to be included. Arrangements to monitor the quality of the service provided that also takes into account the views of the residents needs to be developed in order to increase the quality of the service. This will need to identify the strengths and the areas to be improved in the home and a plan as to how this will be accomplished put into place. The resident’s finances are not safeguarded. The manager is not aware if the previous owner is still involved and receipts are not always clear. All individual entitlement must be determined and arrangements put into place for the residents finances to be managed by representatives of the home. Risk assessments for residents individually are either insufficient or not in place this includes, smoking, mattresses next to beds as examples, falls. In order to make sure that residents are fully protected these will need to be reviewed and put into place. Environmental risk assessments such as equipment and potential fires need to be updated. This will need to include when and how specific equipment are to be tested, maintained and used. 28/11/07 28/06/07 28/06/07 28/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 26 No. 1 2 Refer to Standard OP1 OP3 Good Practice Recommendations Update the service users guide and statement of purpose. Make sure that all residents have a copy available that is in formats to suit their needs. Review the assessments to determine resident’s psychological needs before admittance in order to make sure that staff have the skills and training to meet their needs. Daily records need to record the events and the well being of the residents. Restrictions to residents activities such as a limit on smoking or not leaving the building will need to be clearly recorded, the reasons why and the agreement of the resident will also need to be detailed. Staffing levels need to be reviewed, staff levels should meet the needs of residents and this should be recorded. 3 4 OP7 OP12 5 OP27 Waverley, The DS0000068442.V342385.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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, The DS0000068442.V342385.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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