Care Home: Watford House Residential Home

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What the care home does well The management and staff make the people who use the service and their visitors welcome. There are frequent visitors to the home. Staff demonstrated great respect for the people who use the service, and people were addressed in an appropriate manner. Discussions with staff were positive, and showed a clear determination that they belong to a committed team. People spoken with were very positive about the care that they were receiving. The home was clean, warm and comfortable. Care plans seen were clearly written, and reviews were up to date. They evidenced that people`s health needs were being met What has improved since the last inspection? The Annual Quality Assurance Assessment document completed by the provider and care manager confirmed the following improvements: "New furniture throughout the home, New Televisions, Seating environments have been changed for residents where there condition made their seating arrangements unsatisfactory. This is done through consultation with families. Alternative medical practices i.e. homeopathy employed to a service user who has requested this. New Laundry equipment. A dedicated laundry person has been employed and clothes labelling system, this has lead to clothes no longer being mislaid or mislabelled and residents wearing the wrong garments. Better and more open complaints procedure. A clear statement of purpose and obligations of contract shown and offered to all families and keep on show in the home All staff now where a clear uniform signifying their rank and displaying their NVQ levels or other qualifications." What the care home could do better: New staff must be confirmed in post only following completion of a satisfactory police check, and satisfactory check of the Protection of Children and Vulnerable Adults and National Medical Council (NMC) registers. Care plans should reflect that people`s needs have been re-assessed in regard to risk, and or levels of care required when significant changes have been noted.Pre-admission assessments should be comprehensively completed, and should be included in the care plan paperwork. People who use the service should be consulted about the programme of activities arranged by or on behalf of the care home, and be provided with facilities and activities for recreation, fitness and training. A more comprehensive quality assurance system needs to be implemented which encourages and seeks feedback from people who use the service, their relatives and or representatives, and other visitors to the service. This information should be acted upon and outcomes feedback through staff and resident`s meetings. People who use the service should have a forum for having their say in regard to the running of the home, and there should be feedback given in regard to quality assurance outcomes. CARE HOMES FOR OLDER PEOPLE Watford House Residential Home 263 Birmingham Road Shenstone Wood End Lichfield Staffordshire WS14 0PD Lead Inspector Pam Grace Unannounced Inspection 3rd September 2008 10:45 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 Watford House Residential Home DS0000068404.V371266.R02.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. Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Watford House Residential Home Address 263 Birmingham Road Shenstone Wood End Lichfield Staffordshire WS14 0PD 0121 308 1342 0121 308 0429 watfordhouse@btconnect.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Watford House Residential Home Ltd Ms Kathryn Sonia Bridgeman Care Home 43 Category(ies) of Dementia (18), Old age, not falling within any registration, with number other category (43), Physical disability (17) of places Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 18 Old age, not falling within any other category (OP) 43 Physical disability (PD) 17 The maximum number of service users who can be accommodated is: 43 11th February 2008 2. Date of last inspection Brief Description of the Service: Watford House is a privately owned Care Home registered to provide personal care to a maximum of 43 people. The home is a former farmhouse, which has been altered and extensively extended, and is a building of character. The home, situated on the Staffordshire border near Shenstone, is close to Blake Street railway station and served by a regular bus service. Teams of care assistants, reporting to the registered care manager, provide care. The home is registered to provide accommodation to a maximum of 43 residents, of which eighteen may have dementia, or related conditions and seventeen may have physical disabilities. The buildings are on several floors and have twenty-four single bedrooms and six double bedrooms. A total of seventeen single bedrooms have en-suite facilities. There are five separate lounge and dining areas, which cater for the different groups of people. District nurses, community psychiatric nurses and other professionals are accessed by the home when required. A local GP surgery and pharmacist service the home. NHS facilities and health services are accessed, and assistance is provided for residents to attend, when required. Activities, Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 5 hobbies and entertainment all take place and transport is provided when required. The fees charged for the service at Watford House, are from £320.28 - £420.00 per week. The fee information included in this report applied at the time of inspection, the reader may wish to obtain more up to date information from the care service. Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This key unannounced inspection was carried out over one day, by one inspector. The inspection had been planned using information gathered from the Commission for Social Care (CSCI) database, the Annual Quality Assurance Assessment (AQAA) document that had been completed by the provider and care manager, comments/surveys received from people who use the service and their relatives. The key National Minimum Standards for Older People were identified for this inspection and the methods in which the information was gained for this report included case tracking, general observations, document reading, speaking with staff, people who use the service and their visiting relatives. A tour of the environment was also undertaken. The Statement of Purpose and Service User Guide had recently been reviewed and were available for us to view. The previous inspection report is available to read in the main entrance hallway of the home. At the end of our inspection, feedback was given to the care manager, outlining the overall findings of the inspection, and giving information about the requirements and recommendations that we would make. People spoken with were very positive about the care they were receiving. We observed people who were unable to communicate. Our observations showed that these people were well cared for, and were happy in their surroundings. There had been 2 complaints made to the home, since the previous inspection, one complaint was upheld, and one complaint had been partially upheld. Both complaints had been dealt with in a timely way, under the home’s own complaints procedure by the care manager. Surveys returned to the Commission for Social Care Inspection (CSCI) totalled three `Have Your Say’ documents. The feedback and comments we received from people about the service were generally positive. There was one requirement, and six recommendations made as a result of this unannounced inspection. Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 7 What the service does well: What has improved since the last inspection? What they could do better: New staff must be confirmed in post only following completion of a satisfactory police check, and satisfactory check of the Protection of Children and Vulnerable Adults and National Medical Council (NMC) registers. Care plans should reflect that people’s needs have been re-assessed in regard to risk, and or levels of care required when significant changes have been noted. Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 8 Pre-admission assessments should be comprehensively completed, and should be included in the care plan paperwork. People who use the service should be consulted about the programme of activities arranged by or on behalf of the care home, and be provided with facilities and activities for recreation, fitness and training. A more comprehensive quality assurance system needs to be implemented which encourages and seeks feedback from people who use the service, their relatives and or representatives, and other visitors to the service. This information should be acted upon and outcomes feedback through staff and resident’s meetings. People who use the service should have a forum for having their say in regard to the running of the home, and there should be feedback given in regard to quality assurance outcomes. 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. Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 9 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 Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 - Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. Pre-admission assessments should be comprehensively and clearly completed. EVIDENCE: The Annual Quality Assurance Assessment document (AQAA), which was completed by the provider and care manager, told us: “Information on fees, contracts of service, statement of purpose, leaflets on care issues are all freely available and service users and their families are encouraged to read these before any contracts are signed with the home. Issues from mental health to funding are covered. We comprehensively assess service users in order to ensure that they would be properly placed and that we can meet their needs. Assessements take place Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 11 at Hospital, or at home and a form is used to compile the information. Health workers and social workers all contribute to the assessement. Contracts are clearly written and copies of both statement of purpose and contract are taken away by families. A full days trial visit is then undertaken at no cost to the service user to ensure that the service users needs can be met. An Initial care plan is then formulated on the findings outlined above. Respite or intermediate care – the procedure for respite stays is the same as for permanent stays.” We were given copies of the Statement of Purpose and Service User Guide to look at. We saw that these documents had been reviewed. The previous inspection report was readily available in the entrance hallway, for people to look at. People spoken with, and feedback from surveys undertaken confirmed that they had received appropriate information prior to admission, which had included the Statement of Purpose. That they had been able to visit the home, and spend time talking with people who use the service to help them decide if the service would be suitable for them. People also confirmed that they had been provided with a contract/terms and conditions. The provider confirmed that contracts had all been reviewed. We looked at four care plans. These showed that an assessment of needs had been undertaken for those individuals on admission, however, some preadmission assessments had been archived for people who had been living at the home for many years, and information contained within one pre-admission assessment undertaken for a new admission was very brief, and did not contain enough information. This was highlighted and discussed with the care manager at the time. Intermediate care is not provided in this home. Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. Care plans should reflect the re-assessment of people whose needs have changed. EVIDENCE: The Annual Quality Assurance Assessment document (AQAA), which was completed by the provider and care manager, confirmed the following: “Care Plans are much improved and more person Centred and show a clear picture of service users needs Good Medical procedures and infection control procedures New equipment- hoists New Lockers in Bedrooms for the safe storage of creams etc.. and valuables Respect for privacy and dignity Palliative care discussions with service users’ families Better Care Planning Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 13 Good laundry services- this leads to better infection control and more dignity to the service users in that the correct clothes are worn by the correct service users. Clearly uniformed staff. This allows both service users and families to clearly identify the rank of staff and enable them to make complaints etc to the correct persons. New Professional Medical fridge.” We examined four care plans. We spoke with staff, people who use the service, and their visiting relatives. Staff spoken with could tell us exactly how each of these people were to be cared for, what these staff told us reflected what was written in individuals care plans. People we spoke to told us they had been involved in their care planning processes and their review. However, the care plans seen did not evidence that people using the service had been involved, they were not signed by the individual. Care plans seen had archived evidence of pre-admission assessments, which had informed the care plan. There was also evidence of health professional’s involvement, for example District Nurse, General Practitioner, Chiropodist. Brief details were recorded in the event of terminal illness. Although risk assessments and activities of daily living had been reviewed on a monthly basis, care plan records did not reflect that there had been a re-assessment of need following the discovery of a significant change in a person’s condition. This was highlighted and discussed at the time with the care manager. The care manager confirmed that the tissue viability specialist nurse would be consulted where necessary in relation to a person requiring more complex treatment. District nurse records were evident in relation to wound care and treatment given to people using that service. Those records were kept separately in individual’s bedrooms. People spoken with during our visit said that they were very satisfied with the care they receive, and that they were only to ask for help, and staff gave them help. One person confirmed her satisfaction with the care she was receiving, she said the staff were “very hard working”, “no problems with getting things done.” A spot check of the home’s medication systems evidenced satisfactory and safe practice of medication administration, storage and disposal. A new medication fridge had been purchased since the previous inspection. Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 - Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service should be enabled to make choices about their life style and should be supported to develop their life skills. Social, educational, cultural and recreational activities must meet individual’s expectations. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, which was completed by the provider and care manager, confirmed the following: “Clear choice of food Clear menu Boards Good choice of Lounges with differing daily activities i.e TV, Radio, Reading Lounge, Activity Lounge, Rest Lounge. This encourages social relationships. Good Religious observance Good range of Activities, use of Nintendo Wii, gardening, crafts etc.. Minibus Bus Outings External entertainers.” A visiting minister from the local church was ministering and providing a service to people using the service on our arrival at the home. Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 15 We spoke with the provider, he confirmed that there had been an activities coordinator employed at the home for 4 months, however, this post is now vacant again, and he intends to recruit within the next few months. People spoken with confirmed that they were unable to have their say, as there were no resident’s meetings. This was highlighted and discussed with the care manager at the time. Staff confirmed that they provide activities when time allows. For example playing cards, jigsaws, crossword puzzles, quizzes, bingo. Two volunteers come in to do activities with people twice weekly. The library service visits each Friday. People go out to the pub, and trips out had recently included a trip to the Cannock Teddy Bears factory outlet, where people could make and purchase their own teddy bear. Four weekly rotational and seasonal menus were in place. We looked at the kitchen, which was very clean and tidy. The cook, and records seen confirmed that all hot food temperatures are taken daily and recorded, this is as well as fridge/freezer temperatures. A replacement chest freezer is needed for freezer number one, as the seal is no longer viable. We discussed the need to have a cleaning schedule in place, which will enable monitoring to take place. Watford House Residential Home DS0000068404.V371266.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 – Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure. People are protected from abuse, and have their rights protected. EVIDENCE: We saw that the complaints procedure was displayed in the main entrance to the home. The Annual Quality Assurance Assessment document completed by the provider and care manager confirmed the following: “Clear complaints procedure Rapid response to complaints, often within 24hrs. Complaint procedure is outlined clearly in the statement of purpose and on display Whistle blowing is actively encouraged and Management is available at all times for consultation by families, service users and staff.” The care manager confirmed that people who use the service and or their representatives are provided with a copy of the home’s complaints procedure during the admission process. People spoken with during the inspection visit confirmed that they had been given a copy of the complaints procedure, and knew who to complain to. They said that their grumbles are listened to and acted upon by staff. One relative spoken with said, “my relative can’t speak for himself, if there are problems I Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 17 come in and have a word. The manager is very approachable”. “My relative has been here 10 years without any problems.” The care manager confirmed that the home has an open door policy in regard to complaints. Discussion with the home’s provider confirmed that he often speaks with people who use the service and or their relatives. He sorts out any problems straight away. That’s why he feels that the home does not receive many formal complaints. He confirmed that he has also recently introduced care planning review evenings for relatives, which are proving to be well attended. Complaint records were available for us to view. There had been two complaints since the last inspection, one had been partially upheld and one had not been upheld. The care manager had dealt with both complaints under the home’s policy and procedure. We discussed the need for outcome letters to be included in records kept. The present system is that the provider keeps the outcome letter separately to the main paperwork. There had been no Protection of Vulnerable Adults (POVA)/Safeguarding referrals made to Social Services since the previous inspection. We spoke with staff, and looked at the training matrix. Some staff had not received update or refresher training with regard to adult abuse, its identification and types of exploitation. Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a well-maintained and comfortable environment, which encourages independence. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, completed by the provider and the care manager, confirmed that all health and safety checks on equipment and fire systems had been undertaken, and confirmed the following: “Good programme of decoration and maintenance Compliance with all fire regulations and EHO Many areas of communal space of which all conform to standard and fit for use. No smoking home- a smoking area is provided to the rear of the building Good light and pleasant environment to live. Good quality furnishings Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 19 Provision of hoists and beds Promotion of good hygiene procedures Better laundry facilities Provision of enclosed safe garden for wanderers.” The provider also updated us in regard to the following: “Landscaping and security upgrading the site with gates, fencing, planting and better lighting in outside areas has been completed. Ongoing decoration program, which includes upgrading all fire doors and installing privacy locks on all bedrooms has now been completed. Continuation of carpet replacement. Purchase of two new professional carpet cleaners. Yet to upgrade two old boilers to high efficiency boilers, but this will be done. Upgrade laundry has now been completed. Some furniture has been upgraded. Valuables lockers in all rooms, 6 still to do, these are on order. There is still work in progress on some areas previously identified.” This work was confirmed and seen during our tour of the building. People spoken with during the inspection visit expressed their satisfaction with the general environment, their room, and the equipment provided within the home. People spoken with said, “it’s kept clean and tidy”, and “the staff try very hard to keep it all clean.” We undertook a tour of the environment. The home provides a clean, wellmaintained environment throughout. There were some areas highlighted and noted in regard to the replacement of carpets, and refurbishment, however, these were already known to the provider and the care manager, and were in hand. Accommodation is personalised to suit individuals. Communal areas are comfortable and homely. Bathrooms and toilets are conveniently sited around the home. Bathrooms and en-suites would benefit from some shelving, for people to store personal items. We noted that equipment and adaptations were provided as necessary to maximise independence. For example, wheelchairs, raised toilet seat, bed rails, pressure mattress, handrails, and assisted baths. The bed rail in one shared bedroom was highlighted as needing replacing, as it did not fit properly. This was discussed with the care manager and will be rectified as soon as possible. Bed rail bumpers were in place where needed, to promote the comfort and security of the people using the service. Risk Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 20 assessments were in place within care plans, for individuals who had bed rails fitted. Kitchen and laundry areas were clean and tidy, with appropriate measures in place to prevent cross infection. A copy of the home’s Fire Safety Compliance Certificate had been requested and forwarded to the Commission for Social Care Inspection (CSCI) for our records. Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 - Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, completed by the provider and care manager, confirmed the following: “Excellent Staff Training Program and Support to Staff up to and including NVQ3 in Health and Social Care Good Staffing Numbers Stable Workforce Good Supervision or Service Users Robust Recruitment Procedures. Training has been outsourced and only a small percentage of training is now carried out in house.” Staff rotas for August confirmed the following staffing levels, and these had not changed since the previous inspection: One senior care plus five carers 7am – 2pm One senior care plus five carers 2pm – 9pm One senior care plus two carers 9pm – 7am (nights) Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 22 The home has two domestic staff working from 7.00am – 2.00pm. The cook worked from 7.00am – 2.00pm And a maintenance person worked from 8.00am – 5.00pm. Staff, people spoken with during the inspection visit, and surveys received from people who use the service, confirmed that staffing levels had been maintained. Staff spoken with confirmed that staff meetings were being held approximately three monthly, and that supervision of staff was being held every eight weeks, as per the National Minimum Standard. They confirmed that they had received updates in regard to mandatory training, including moving and handling, health and safety, Fire and Medication. However, we were provided with a copy of the home’s staff training matrix, which evidenced that some care staff had not undertaken moving and handling, infection control and abuse training. Four staff recruitment files were examined. Three contained all the appropriate security/police checks, and evidenced a good standard of procedures from an administrative point of view. However, one staff member’s file did not evidence that a Criminal Records Bureau check had been undertaken, this staff member had reportedly left the home’s employ, and had some months later returned, it is a requirement of this report that all staff employed at the home must have a Criminal Records Bureau/Protection of Vulnerable Adults check prior to commencement of employment. Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 37 and 38 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect. The home should further develop its quality assurance system to make sure that services are provided in the best interests of those who use them. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) document, which was completed by the provider and care manager, was returned to the Commission for Social Care Inspection following an extension of time, and was well completed. Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 24 The Annual Quality Assurance Assessment document confirmed the following: “Good Dedicated Manager Good Numbers of management on duty at any time, i.e two directors on site generally daily. Clear lines of Communication between staff and management Good robust financial records kept for both the running of the home and service users Good training.” A financial spot check revealed that the provider had just completed a financial audit. Monies held by the home on behalf of people using the service, tallied with the amounts recorded. Goods purchased on behalf of people using the service were receipted and accounted for. The care manager is trying hard to improve the quality of the documentation and recording of individual risk assessments and the reviewing of care plans for people who use the service. To this end, all care staff had received training in care planning since the previous inspection. There had been two complaints made to the home since the previous inspection, one had been partially upheld and one had not been upheld. The care manager had dealt with both complaints under the home’s policy and procedure. The training matrix evidenced that some care staff needed update and refresher training in regard to moving and handling, infection control and adult abuse. Staff spoken with confirmed that they were receiving supervision as per the National Minimum Standard (NMS), and could readily recall the date of their previous session. There should be a forum for people using the service to have their say in the general running of the home. This should include menus, activities, the recruitment of staff, and feedback from surveys undertaken by the service. Quality assurance systems should be expanded to include other health professionals. Results from surveys should be collated and feedback to people using the service and staff. Watford House Residential Home DS0000068404.V371266.R02.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 3 3 2 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 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 X 3 3 3 Watford House Residential Home DS0000068404.V371266.R02.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 OP29 Regulation Sch2(7) Requirement New staff must be confirmed in post only following completion of a satisfactory police check, and satisfactory check of the Protection of Children and Vulnerable Adults and NMC registers. Timescale for action 03/09/08 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 OP3 OP7 Good Practice Recommendations Pre-admission assessments should be comprehensively completed, and should be included in the care plan paperwork. Care plans should reflect that people’s needs have been re-assessed in regard to risk, and or levels of care required when significant changes have been noted. Plans of care should clearly evidence involvement by the individual and or their representative, and be dated, to ensure that people are aware and agree to the plan. 3. OP7 Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 27 4. 5. OP12 OP12 6. OP33 Some consideration should be given in regard to the provision of activities for people who have dementia and or a limited ability to communicate. People who use the service should have a forum for having their say in regard to the running of the home. This is in relation to their daily menus, activities, recruitment of staff and feedback from quality assurance surveys. The existing quality assurance system should be further developed to include health professionals, and should also be based upon seeking the views of people using the service and visitors to the service. This information should be collated, acted upon, and outcomes feedback through staff and resident’s meetings. Watford House Residential Home DS0000068404.V371266.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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