Care Home: Waterloo House

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What the care home does well Waterloo HouseDS0000000639.V375893.R01.S.docVersion 5.2Waterloo House provides a friendly caring environment. One service user survey included the comment; " staff and management are always willing to help." The staff make visitors welcome and offer support, such as refreshments and help with outings. Care is planned and recorded in detail, so that service users and staff know how care will be delivered. One service user survey included the following comment; " The care for the individuals is excellent and the particular needs of each one is catered for." One staff survey:" provides quality care to Residents, put the needs of the Residents first." The menus offer choice, mealtimes are flexible and alternatives are arranged so that service users can make their own arrangements. The people who live at the service are encouraged and supported to get out into the local town. The home is well staffed and service users are cared for in an unhurried and relaxed manner. The staff support people who live at the service to live the life they choose. Staff receive good basic training, refresher training and have opportunities to take qualifications in care and special training. This means that the people who use the service and their representatives have confidence in the staff. What has improved since the last inspection? What the care home could do better: Key inspection report CARE HOMES FOR OLDER PEOPLE Waterloo House Waterloo Road Blyth Northumberland NE24 1BY Lead Inspector Carole McKay Key Unannounced Inspection 4th June 2009 09:00 DS0000000639.V375893.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waterloo House Address Waterloo Road Blyth Northumberland NE24 1BY 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) 01670 351992 01670 356328 Mr Sewa Singh Gill Mrs Brenda Nicholson Care Home 46 Category(ies) of Dementia - over 65 years of age (12), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (33) Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2008 Brief Description of the Service: Waterloo House is a two storey adapted building. The home does not have gardens, though there re raised flower beds and mature trees at the entrance to the car park. A small sitting out area is located near the front entrance to the home. Parking for a small number of cars is available at the front of the home within a general amenity area. The home is well located, in walking distance of the centre of Blyth. Bedrooms and communal areas are distributed across both floors and the office/reception area is immediately inside the main entrance hallway. The home has a large established staff team of ancillary, care, and senior care staff plus one manager. Waterloo House is registered to care for older people and people with dementia who are also over 65. Fees for the home range from £429.56 to £435.13 Hairdressing, newspapers, taxis and private chiropody are charged for separately. Waterloo House DS0000000639.V375893.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 2 star. This means the people who use this service experience good quality outcomes. In line with current CSCI policy on ‘Proportionality’ the inspection focused upon a number of key standard outcomes for service users. How the inspection was carried out Before the visit: We looked at: • Information we have received since the last key inspection visit on 1 August 2008. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service. • We also sent out surveys to staff and service users to complete. None of these had been returned at the time of this report being completed. The Visit: An unannounced visit was made on 4 June 2009. During the visit we: • • • • • • Talked with people who use the service, staff and the manager. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. What the service does well: Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 6 Waterloo House provides a friendly caring environment. One service user survey included the comment; “ staff and management are always willing to help.” The staff make visitors welcome and offer support, such as refreshments and help with outings. Care is planned and recorded in detail, so that service users and staff know how care will be delivered. One service user survey included the following comment; “ The care for the individuals is excellent and the particular needs of each one is catered for.” One staff survey:” provides quality care to Residents, put the needs of the Residents first.” The menus offer choice, mealtimes are flexible and alternatives are arranged so that service users can make their own arrangements. The people who live at the service are encouraged and supported to get out into the local town. The home is well staffed and service users are cared for in an unhurried and relaxed manner. The staff support people who live at the service to live the life they choose. Staff receive good basic training, refresher training and have opportunities to take qualifications in care and special training. This means that the people who use the service and their representatives have confidence in the staff. What has improved since the last inspection? The décor has been repainted in the dining room and it feels fresher and brighter. New arrangements for staff supervision have been introduced. This will help staff to keep up with changes and build on their skills for supporting service users. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 7 The procedures for handling the money belonging to service users have changed, to make the system safer and avoid errors. This protects the best interests of service user. The records to do with the care of service users are now kept out of view and are more secure. This protects the privacy of service users. The manager now has better resources to support her in caring for the service users. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Waterloo House DS0000000639.V375893.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 Waterloo House DS0000000639.V375893.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home does not provide intermediate care. Standard 6 was not assessed. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who come to live at the home will have their needs assessed so that they will be assured these can be met. EVIDENCE: The home has made several new admissions in the last year. The service user plans for two people more recently admitted were examined during the visit. These showed that the home had obtained an assessment from each person’s care manager prior to admission. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 10 The assessment process is comprehensive and includes risk assessments and management plans for identified risk. These are linked to the assessment provided by the care manager. In a survey a care manager responded that the service usually ensures that accurate information is gathered and that the right service is planned for people. Since the last inspection the home has further developed its use of specialist risk assessments, for example assessment tools are used for general dependency, safeguarding liberty and managing potential harm. This is an example of how the home is keeping up to date with current best practice in assessment. Waterloo House DS0000000639.V375893.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the service will have their health care needs safely met in ways that they prefer. EVIDENCE: The service user plans for six of the people living at the home were examined.. These showed that the each person has an up to date plan. These had been evaluated in the past month. Each plan included specific risk assessments for general dependency, falls, nutrition, pressure sores and moving and transferring. Some of the tools used to identify risk and provide support have been replaced with more up to date, or specialist versions; such as those for preserving liberty and managing potential harm. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 12 The home has received an accredited award for staff training in falls prevention. A process of monitoring and analysing falls has been introduced and the manager is about to update this also. Management plans were in place to address the risks. Specific plans were in place for supporting people with personal care, where this was an identified need. These were detailed and described the action staff needed to take as well as the things the person could, or preferred to do themselves. The plans have a section for recording care provided by other health professionals. These show a good level of involvement for GPs, and district nurses. Many of the people who live at the service have a degree of dementia. For some people this may mean that at some time in the future they may not have the capacity to make decisions about things that affect or involve them. The service user plans now include a plan for addressing this when, and if, the time comes that decisions have to be made. The plan acts as a reminder to the staff that these matters will need to be considered. Other plans are in place to address individual health needs, such as – a care plan for supporting a person who needed to have food cut up very small. In circumstances such as this the home does refer to outside specialists for guidance and builds this into the plan of care. And there is evidence that they will try to promote and support the wishes of the service user, with agreement of the specialist involved. In a letter to the manager a relative had given very high praise to the home for the care and attention received by one service user during a recent period of ill health. The manager described how relatives of service users have been involved in providing useful information to do with long standing care needs. Most service users require their medication to be managed for them. The home has not changed the storage arrangements for this since the last inspection, so this was not examined during this visit. But the manager has updated the medication procedure, has introduced an auditing process and a system for assessing the competence of staff, once they have been trained to administer medication. The procedure and the records were examined and these were satisfactory. Waterloo House DS0000000639.V375893.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 . People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the service will have their lifestyle choices and interests upheld as far as is possible and in accordance with their abilities and expectations. EVIDENCE: The hallway of the home is immediately welcoming, as are the staff. The hall has pictures and information boards, a sweet dispenser and suggestion box with pens and paper to hand. The manager has introduced an activity record. This shows that service users can take part in in- house activity such as dominoes, music and going shopping and for short walks. For some people going for a walk with staff is part of their care plan to avoid people leaving the home unaccompanied, where there is a risk to their safety for them to do so. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 14 Those people who like to wander around the home are able to do so and staff will sometimes accompany them and gently engage people in conversation as they do so. Music was playing in the lounge at the time of the visit. Some people were singing along with the staff. St John’s library provides a reading service. For one person who always had fresh flowers at home each week, the staff have organised for this to continue. The home has organised for some service users to have a daily paper delivered. For one person this is important as he follows the horse racing. Bingo and dominoes are played, and the home has other organised events, an example was given that an outing to a new local restaurant is being organised. There is information about forthcoming activities in the hallway and photographs of events are taken and displayed. The visitors’ book shows a good level of involvement and the manager refers to service users’ family members by first name and can account for various occasions when she has consulted with them about activities people have previously enjoyed. Staff support family members to take relatives out of the home, by helping to have the person ready for the outing, or being flexible with mealtimes. Staff support service users to get out of the home, either to sit out on the patio or to go for short walks or shopping. The manager said that the following activities are also promoted; doll therapy ( for one person), memory lane, reminiscence activities, a sing along in German ( for one person), regular sing along and music sessions. The manager is trying to re establish the committee and said that three relatives have come forward to sit on this. Two service usesr are keen to be involved. In a survey a care manager responded that the service always supports people to live the life they choose and always responds to the diverse needs of individual people. The following comment was also included in response to what the service does well; “1. Responds positively to individual/diverse needs of clients which may ‘put off’ other homes on referral. 2. Much more sympathetic and tolerant to the behaviours which MH residents can present. 3. Makes clients/residents their priority:…” Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 15 And another professional survey observed that the service “ has previously supported people to adapt to living in their establishment who have had difficult and often challenging behaviours” Since the last inspection the service has distributed to staff a handbook about equality and diversity. The experienced care staff are readily able to describe in detail the likes, dislikes and preferences of individual service users. The menus for the home are extensive. They provide a choice of two meals at each main mealtime and two cooked meals per day. The menu plan rotates every six weeks. The cook has a file that includes the individual preferences and special needs for each of the people living at the home. And a folder of photographs of main meals has been put together, as an aid to people making informed choices. This is also in the kitchen. Service users can take their morning coffee and afternoon tea in their own cup and these are kept on the tea trolley. The dining room has been redecorated but the décor is rather plain and featureless. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager welcomes comments from the people who live at the home and their representatives. Concerns are responded to and the service protects its service users. EVIDENCE: The home has a complaints policy and procedure. A copy of this is posted in the hallway and is available in the welcome pack. The suggestion box is nearby and is used. Copies of compliment letters are also displayed with permission of the writers. The Care Quality Commission ( CQC) (previously the Commission for Social Care Inspection (CSCI)) has not received any complaints. The home keeps a complaints record. The last entry was dated 3/06/08. The matter had been fully investigated and the action taken was fully recorded. In a survey a care manager responded that the service has always responded appropriately if concerns have been raised. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 17 All staff have received training to do with protecting vulnerable adults. The home’s procedures have been revised in consultation with the local safeguarding team. The home has copies of the local procedures for safeguarding people from abuse. These are included in a file of guidance to do with safeguarding service users. Copies of government guidance documents and codes of practice are also available. The file is used for training staff and as a reference. It includes the home’s own ‘whistleblowing’ procedure. Staff have also had some in house training regarding the law and people being able to make decisions, as well as guidelines to do with managing behaviour. The home has up to date information to do with protecting the freedom and safety of service users, and senior staff have attended training in this matter. Since the last inspection the service has shown that staff will raise concerns and that the management team will address these by referring matters to the police and to the safeguarding authority. This action has protected service users at the home and in the wider community. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a clean and safe place for service users to live, where they can personalise their private space but one which does not best meet their needs and expectations. EVIDENCE: Since the last inspection some improvements have been made to the home. Some of the bedrooms have been totally redecorated. These are decorated in different colours and styles. The dining room has had the old wallpaper removed and has been painted. The dining room carpet has been replaced. The main corridors have been repainted in places. Although this makes for a cleaner looking environment, these areas are rather bare and featureless. And the pale walls, doors and patterned carpets are not ideal for an environment where people with dementia are living. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 19 Service users can personalise their rooms. Many of the rooms have small items of furniture that belong to service users as well as soft furnishings, photographs, ornaments and other belongings. Most rooms have en suite facilities. Externally the flower beds are being tidied and the patio is in use. The surveys we sent out, and those that have been issued by the service, reflect the environment as letting the service down overall. The home is in parts very old and is not easy to clean and maintain. It is to the credit of the cleaning staff and the handyman that the home is kept very clean and in safe repair. However the size of the home warrants further resources and expenditure to make a significant improvement in the general quality of the environment. Especially to provide a suitable level of décor for supporting people who have dementia. For example plainer carpets and a better use of colour contrast would help service users distinguish different areas of the home. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at the home will have their needs met by well recruited and trained staff. EVIDENCE: The home has low staff turnover. Only three members of staff have left in the past twelve months. Six care staff were on duty at the time of the visit with two cleaning staff, one laundry staff, one cook, one kitchen assistant. 17 of the 20 care staff hold a national vocational qualification (NVQ) in care at level 2 or above. Other staff are working towards this. The file of two of the more recent staff to be recruited confirmed that they had received thorough induction and had been able to be take up NVQ training immediately after this. All long term staff have undertaken a ‘B.Tec’ training in dementia awareness. The domestic staff have undertaken NVQ training also. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 21 The staff files were examined and these show that staff are able to take up basic and further training opportunities related to the care of older people. The home uses a training agency and they can rely on the agency to update mandatory training as a matter of routine. The manager has a training schedule and the assistant manager is using supervision and group supervision as an opportunity to update training. The staff files are in good order and regular one to one supervision has been re- established. The records of this are well structured and they show that it is a two way process. Annual appraisals are also being carried out. Staff recruitment is a clear process. The files that were examined had evidence of full applications, clear recruitment checks, appropriate references and records of interviews. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed in a spirit of openness and consultation. Service users’ needs are met by taking account of their feelings and opinions. The written procedures for safeguarding service users’ interests do not reflect the current practice. EVIDENCE: Brenda Nicholson is registered as the manager and holds the registered manager’s award. Brenda has held this position for twelve years and is well regarded among the staff team and the representatives of the people who use Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 23 the service. Recently Brenda undertook training related to care of older people. She now has a personal training plan for the coming year. The home’s management structure has been revised since the last inspection and Brenda has a designated assistant manager. Brenda reports to Mr Gill, the provider, and he appoints an employee to carry out monthly checks of the service on his behalf. Reports from these visits are produced and these include the views of the service users. Other people and agencies with an interest in the service have been surveyed. Brenda said that she is nearer now to re-instating the residents/relatives committee. There is an annual quality check carried out, and this has addressed matters to do with the upkeep of the building. Brenda can call upon the services of other contractors for routine servicing and repair of installations. Brenda now has more resources and space for administrative tasks. Where service users cannot, or prefer not to hold on to their own money, then this is securely stored as separate amounts and individual account books are kept. Brenda has revised the arrangements for access to service users’ money and she now has control of this process. The written procedure has been updated. The home now has a computer, internet and e-mail facility. This means that Brenda can access up to date guidance documents. The handyman carries out the safety checks for the building, including the fire safety, water safety checks. The home has up to date guidance to do with infection control. Staff have received training in infection control. One of the staff acts as liaison for the infection control team and provides training and carries out audits. Portable appliance tests had been carried out in July 2008. Lifts and hoists have been serviced this year. As have fire safety appliances and equipment. The electrical circuits safety check was being carried out at the time of the visit. We spoke to the person carrying out the check. He told us that he had the agreement of the provider for him to carry out the remedial work, after which he would be issuing a new certificate. Written confirmation of this has been received. Information provided by the manager shows that the home has assessments for hazardous substances and that staff have received training in food hygiene. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 24 One safety hazard was noted and this was drawn to the attention of the manager and addressed at the time of the inspection. However the manager had not been made aware of this by the staff. Accidents are fully recorded but these are not monitored and reviewed to take account of recurrences, trends and patterns. The environmental health officer visited the service in 2007. There are no matters outstanding from this visit. The home has had window restrictors fitted to rooms on the first floor. Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X n/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 4 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 2 X X X X x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 3 X 2 Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 26 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. 1. Standard OP19 Regulation 23 Requirement The registered manager must review the décor, carpeting and signage in the home with reference to guidance relevant to homes for people with dementia. And produce an action plan for improvement. This will provide for an environment more suited to the needs of the service users and the stated aims and objectives of the service. 2. OP19 23 The on going maintenance and refurbishment plan must be kept up to date. This will ensure service users experience an improving environment. Safety hazards must be reported to the person in charge immediately and addressed as soon as possible. This will ensure service users are kept safe. 30/10/09 Timescale for action 30/10/09 3. OP38 13 31/08/09 Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 27 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. 2. Refer to Standard OP15 OP20 Good Practice Recommendations Improve the décor in the dining room. To provide more pleasing surroundings to service users for taking meals. Improve the landscaping to the flowerbeds and improve the patio by use of planters and some screening. To provide more pleasing surroundings for service users. Accident records should be monitored for patterns and trends. This will help eliminate unnecessary risks 3. OP38 Waterloo House DS0000000639.V375893.R01.S.doc Version 5.2 Page 28 Care Quality Commission North Eastern Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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