We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

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1 Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Waterside Care Centre Leigh Sinton, Malvern, WR13 5EQ Tel: Date of Inspections: 29 April April 2014 Date of Publication: May 2014 We inspected the following standards as part of a routine inspection. This is what we found: Consent to care and treatment Care and welfare of people who use services Management of medicines Safety, availability and suitability of equipment Assessing and monitoring the quality of service provision Inspection Report Waterside Care Centre May

2 Details about this location Registered Provider Registered Manager Overview of the service Type of service Regulated activities Minster Care Management Limited Mrs Julia Patricia Roberts Waterside Care Centre provides care and nursing for older people who need support; this includes older people living with dementia. Care home service with nursing Accommodation for persons who require nursing or personal care Diagnostic and screening procedures Treatment of disease, disorder or injury Inspection Report Waterside Care Centre May

3 Contents When you read this report, you may find it useful to read the sections towards the back called 'About CQC inspections' and 'How we define our judgements'. Summary of this inspection: Page Why we carried out this inspection 4 How we carried out this inspection 4 What people told us and what we found 4 More information about the provider 6 Our judgements for each standard inspected: Consent to care and treatment 7 Care and welfare of people who use services 9 Management of medicines 10 Safety, availability and suitability of equipment 12 Assessing and monitoring the quality of service provision 13 About CQC Inspections 15 How we define our judgements 16 Glossary of terms we use in this report 18 Contact us 20 Inspection Report Waterside Care Centre May

4 Summary of this inspection Why we carried out this inspection This was a routine inspection to check that essential standards of quality and safety referred to on the front page were being met. We sometimes describe this as a scheduled inspection. This was an unannounced inspection. How we carried out this inspection We looked at the personal care or treatment records of people who use the service, carried out a visit on 24 April 2014 and 29 April 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members and talked with staff. We used the Short Observational Framework for Inspection (SOFI). SOFI is a specific way of observing care to help us understand the experience of people who could not talk with us. What people told us and what we found We considered all the evidence we had gathered under the outcomes we inspected. We used the information to answer the five questions we always ask; Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well led? This is a summary of what we found- Is the service safe? We saw that people who used the service felt safe at Waterside We saw that staff were kind and friendly towards them and usually provided the care and support they needed. People were usually involved in day to day decisions and could make choices about what support they needed. People's care records had been completed and these generally matched their individual care needs. We found that risk assessments were usually in place and that these made sure that people were not placed at risk of inappropriate care and support. Systems were in place to manage people's medicines. These were not always sufficiently safe to ensure that people had received medicines and treatments in line with instructions. We were assured that improvements would take place. We found that equipment had been checked and serviced at regular intervals to ensure it Inspection Report Waterside Care Centre May

5 was safe to use Systems were in place to make sure that managers and staff learnt from accidents and incidents. We saw that suitable action had been taken to reduce accidents and the risks to people. Systems were also in place to ensure that equipment was clean and safe to be used by staff. The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberties Safeguards which applies to care homes. The provider had policies and procedures in relation to the Mental Capacity Act and Deprivation of Liberty Safeguards (DoL's). We found that staff had knowledge of DoL's. This meant that people would be safeguarded as required. Is the service effective? People's health and care needs were assessed and care and treatment was planned and delivered in line with their individual needs. We found that relatives had been involved but this was limited. We found from our observations and from speaking with staff that they had a good understanding of people's care and support needs. We found that people's mobility and mental health care needs had been taken into account in relation to the environment. Is the service caring? We saw that staff treated people kindly. We saw staff interactions were often supportive and respectful. Staff assisted people sensitively, whilst at the same time promoting their independence as much as possible. We saw that staff supported people and provided comfort and reassurance and usually gave people time to respond. We saw that staff respected people's choices and they helped people to promote their own independence. We found that people were able to make choices about their food and drink and where they spent the day. Is the service responsive? We saw that people's views had been sought through satisfaction surveys. We found that people were confident that any issues they had would be responded to in a timely way. People received help and support from health care professionals when required such as doctors, dentist and chiropodists. Is the service well led? The registered manager had worked with other health care professionals and other services to ensure that people received the appropriate level of care they needed. The quality of the service provided had been regularly assessed and monitored by the registered manager and the provider. The systems used had included obtaining the views of people who used the service and their relatives. We saw that records identified any shortfalls and the actions taken to address these and make improvements. Staff told us they received supervision. Staff felt supported by the registered manager. Inspection Report Waterside Care Centre May

6 You can see our judgements on the front page of this report. More information about the provider Please see our website for more information, including our most recent judgements against the essential standards. You can contact us using the telephone number on the back of the report if you have additional questions. There is a glossary at the back of this report which has definitions for words and phrases we use in the report. Inspection Report Waterside Care Centre May

7 Our judgements for each standard inspected Consent to care and treatment Before people are given any examination, care, treatment or support, they should be asked if they agree to it Our judgement The provider was meeting this standard. Before people received any care or treatment they were usually asked for their consent and the provider acted in accordance with their wishes. Reasons for our judgement During our inspection we observed how people who used the service were supported by staff throughout the day. We saw and heard some positive interactions between staff and people. We found that before people received any care or treatment they were usually asked for their consent. From our observations we saw that staff acted in accordance with their wishes when consent had been requested. Staff told us that they often knew that people consented by their body language and how people reacted to them. We saw many occasions where staff offered positive encouragement to people and we saw staff regularly provided people with choices. For example we saw staff offer people choices in relation to meals and drinks. During our inspection we saw that staff respected people's choices as they made day to day decisions. We saw staff usually sought consent from people before they fitted protective clothing on them before they ate. The provider may wish to note that we saw occasions when people were not consulted or their wishes may not have been taken into account. For example we saw one person had their mouth wiped without any consultation or indication that it was about to happen. This meant that some of the care provided was focused on a task rather than personal care. We looked at parts of three people's records. Records showed that care plans were regularly reviewed to reflect people's care needs when they changed. Records contained information about people's relatives and when they had been contacted for different reasons. The area manager who was present during our inspection was aware of issues around the provision of care and treatment in the least restrictive way. We were informed that an application under the deprivation of liberty (DoL's) needed to be submitted to the local authority for at least one person. We spoke with two nurses, a senior care and a care worker. We found that these staff were aware of DoL's and their responsibilities. This meant that the provider had made arrangements to ensure that staff had an understanding Inspection Report Waterside Care Centre May

8 of their responsibilities to protect people. Inspection Report Waterside Care Centre May

9 Care and welfare of people who use services People should get safe and appropriate care that meets their needs and supports their rights Our judgement The provider was meeting this standard. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. Reasons for our judgement We saw that although some staff did not always consult and engage fully with people who used the service they nevertheless had a kind and caring approach towards people they supported. The atmosphere within the home was calm and relaxed throughout our inspection. We saw that people who were able to mobilise were able to freely walk around the unit on which they lived without staff restriction. Due to people's dementia it was not possible to ask people for their views of the service provided. However we saw that people responded well to staff and people appeared content with the care provided. Signage was displayed within the home to assist people find their way around. We saw that snacks were available for people to have when they wished. We spoke with a relative we told us that they found staff to be: "Very attentive and caring about what they do". We saw that people's medical conditions had been recorded. We saw that staff had recorded when medical professionals had visited and carried out treatment. We saw that doctors, dentists and chiropodists had attended to meet people's needs. A relative confirmed that the staff had: "Dealt with things promptly" and that staff were: "On the ball" when medical attention had been needed. The same relative told us that they were confident that things would be addressed and told us that they felt the person was safe at Waterside. We found that staff were knowledgeable about the care and welfare needs of the people who used the service. The provider may wish to note that we received some conflicting information from different staff members about people's care needs. We found conflicting information in one person's care plan. This meant that inappropriate care could have taken place which was not in line with the person's best interests. We saw that care plans were in place which usually contained the information staff needed to ensure their individual needs were met. We saw that these plans were regularly updated. We saw that risk assessments were in place and that these usually corresponded with each other and reflected the care we saw provided Inspection Report Waterside Care Centre May

10 Management of medicines People should be given the medicines they need when they need them, and in a safe way Our judgement The provider was meeting this standard. People were usually protected against the risks associated with medicines because the provider had arrangements in place to manage medicines. Reasons for our judgement During our inspection we assessed whether there were appropriate arrangements in place for recording, handling, safe keeping and safe administration of medicines. We saw that staff recorded medicines received and administered on people's medication administration record (MAR) sheets. We saw that the majority of the records were completed fully. Records were held of samples of staff signatures to enable them to identify staff signatures on the MAR sheets. This meant that we were able to recognise who had administered medication. We looked at some medicines held in a monitored dosage system provided by the pharmacy. We found that these medicines balanced. We saw that when medicines had not been administered for a particular reason that this was usually recorded. The provider may wish to note that we saw that some staff had occasionally used either a code and not explained why they had used it or used a code not listed on the key. This meant that it was not always possible to fully audit medicines when these codes had been used. We also found that staff had not always recorded when medicines were booked into the home or had not recorded a carry forward from a previous month. This meant that we could not always audit these items to ensure that systems were safe and effective. We saw that regular audits of medicines had taken place. We did some random checks of medicines that were held in their original boxes and found that the balances of medicines that remained did not always balance. The provider may wish to note that we spoke with the two nurses about this and they were unable to account for some of the medicine discrepancies that we found. We were told by the nurses that improvements would take place so that we could be assured that people had always received their medicines as prescribed. We saw that some staff had occasionally used either a code and not explained why they had used it or used a code not listed on the key. This meant that it was not always possible to fully audit medicines when these codes had been used. On our arrival at the home we saw some medication which had been left unsecure and Inspection Report Waterside Care Centre May

11 therefore available to unauthorised persons. During the inspection we saw two tablets which had been sucked and spat out. One tablet was on the floor while the other was on a chair. Although staff were seen to pass these tablets there were not noticed. This meant that these tables could therefore have been accessed by an unauthorised person or a person who used the service. Suitable arrangements were in place to store and administer medicines classed as controlled drugs. This means that special arrangements have to be in place and separate records are maintained to ensure they are kept safely. We audited these items and found that the arrangements were suitable and the contents correctly balance. We saw that fridge was provided to store medicines which needed such a facility. Records were maintained to ensure that these items were kept at a suitable temperature in line with manufactures guidelines. This meant that arrangements were in place to ensure these items were suitably maintained. We saw that MAR records were signed by the nurse on duty. Staff told us that it was care workers who applied the majority of these creams. We were informed that care workers and nurses communicated to ensure that creams had been applied before the record was completed. We found that creams in bedrooms and applied by care workers did not always match the creams signed for by the nurse. We brought what we had found to the attention of the area manager who assured us that an alternative system would be put into place to ensure that records were completed by people who had carried out the treatment. Inspection Report Waterside Care Centre May

12 Safety, availability and suitability of equipment People should be safe from harm from unsafe or unsuitable equipment Our judgement The provider was meeting this standard. People were protected from unsafe or unsuitable equipment. Reasons for our judgement People were protected from unsafe or unsuitable equipment because the provider carried out regular safety checks. We saw that staff knew how to use equipment such as hoists to assist people correctly. The provider had a schedule in place for the equipment used in the home. The schedule covered equipment used to support people's mobility such as lifts and hoists. It also covered safety equipment such as fire alarms, fire extinguishers, gas and portable electrical equipment. We saw that routine servicing of equipment used to lift people had taken place. At the time of our inspection maintenance was taking place. This meant that the provider made sure that equipment remained in good condition and fit for purpose. Where people needed specialised equipment to support them we saw that the provider had completed a risk assessment to make sure that the risks associated with its use had been minimised. We saw that pressure relieving equipment was in place and that these items were set at the correct level. This meant that equipment was in place to support people appropriately. We watched staff using equipment to help people to mobilise. We saw that they did this sensitively and provided constant reassurance as well protecting the person's privacy and dignity. Staff we spoke with told us that they had received training to ensure that they had the skills required to move people safely. This meant that staff were able to use equipment correctly to meet people's needs. Inspection Report Waterside Care Centre May

13 Assessing and monitoring the quality of service provision The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care Our judgement The provider was meeting this standard. The provider had an effective system to regularly assess and monitor the quality of service that people receive. Reasons for our judgement We looked at the quality monitoring processes that the provider had in place. We found that the registered manager although not present during the inspection had a range of systems in place. We saw that the provider had devised a form which was used on a monthly basis to evaluate the care provided and systems in place to ensure that the service was responsive, effective and well led. The form was at times completed by the registered manager and other times by the area manager. The form was always submitted to the area manager so it could be monitored. We saw that any actions required were recorded and followed up as part of the next audit. We saw that relatives were asked for comments about the service provided. The comments we saw were primarily positive. For example 'We as a family love Waterside, caring, empathetic and responsible professional staff' and 'I am confident my mother receives first class care in all aspects'. We were told by the area manager that the registered manager had in the past held relatives meetings. We were told that these no longer took. This was because relatives had stated that they were happy to see the registered manager at times when they visited or as part of the 'manager's surgery' when they made themselves available for relatives to have a discussion about the care provided. Since the last inspection the Care Quality Commission have not received any complaints about the service provided. The area manager was aware of a recent verbal complaint and was awaiting any written follow up in order that it could be fully investigated. We saw that the manager had carried out some audits of the service provided. For example accidents and incidents were evaluated to try and see why people had fallen. This was done to try and reduce accidents. We saw that audits had been carried out on the management of medicines and the records kept. Staff we spoke with were complementary about the management of the home and the Inspection Report Waterside Care Centre May

14 support they had received. We saw that staff had received regular supervision from one of the nurses. However saw that the frequency when nurses received supervision was not as regular to ensure that they also received the necessary support. Inspection Report Waterside Care Centre May

15 About CQC inspections We are the regulator of health and social care in England. All providers of regulated health and social care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The essential standards are described in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations We regulate against these standards, which we sometimes describe as "government standards". We carry out unannounced inspections of all care homes, acute hospitals and domiciliary care services in England at least once a year to judge whether or not the essential standards are being met. We carry out inspections of other services less often. All of our inspections are unannounced unless there is a good reason to let the provider know we are coming. There are 16 essential standards that relate most directly to the quality and safety of care and these are grouped into five key areas. When we inspect we could check all or part of any of the 16 standards at any time depending on the individual circumstances of the service. Because of this we often check different standards at different times. When we inspect, we always visit and we do things like observe how people are cared for, and we talk to people who use the service, to their carers and to staff. We also review information we have gathered about the provider, check the service's records and check whether the right systems and processes are in place. We focus on whether or not the provider is meeting the standards and we are guided by whether people are experiencing the outcomes they should be able to expect when the standards are being met. By outcomes we mean the impact care has on the health, safety and welfare of people who use the service, and the experience they have whilst receiving it. Our inspectors judge if any action is required by the provider of the service to improve the standard of care being provided. Where providers are non-compliant with the regulations, we take enforcement action against them. If we require a service to take action, or if we take enforcement action, we re-inspect it before its next routine inspection was due. This could mean we re-inspect a service several times in one year. We also might decide to reinspect a service if new concerns emerge about it before the next routine inspection. In between inspections we continually monitor information we have about providers. The information comes from the public, the provider, other organisations, and from care workers. You can tell us about your experience of this provider on our website. Inspection Report Waterside Care Centre May

16 How we define our judgements The following pages show our findings and regulatory judgement for each essential standard or part of the standard that we inspected. Our judgements are based on the ongoing review and analysis of the information gathered by CQC about this provider and the evidence collected during this inspection. We reach one of the following judgements for each essential standard inspected. This means that the standard was being met in that the provider was compliant with the regulation. If we find that standards were met, we take no regulatory action but we may make comments that may be useful to the provider and to the public about minor improvements that could be made. Action needed This means that the standard was not being met in that the provider was non-compliant with the regulation. We may have set a compliance action requiring the provider to produce a report setting out how and by when changes will be made to make sure they comply with the standard. We monitor the implementation of action plans in these reports and, if necessary, take further action. We may have identified a breach of a regulation which is more serious, and we will make sure action is taken. We will report on this when it is complete. Enforcement action taken If the breach of the regulation was more serious, or there have been several or continual breaches, we have a range of actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers include issuing a warning notice; restricting or suspending the services a provider can offer, or the number of people it can care for; issuing fines and formal cautions; in extreme cases, cancelling a provider or managers registration or prosecuting a manager or provider. These enforcement powers are set out in law and mean that we can take swift, targeted action where services are failing people. Inspection Report Waterside Care Centre May

17 How we define our judgements (continued) Where we find non-compliance with a regulation (or part of a regulation), we state which part of the regulation has been breached. Only where there is non compliance with one or more of Regulations 9-24 of the Regulated Activity Regulations, will our report include a judgement about the level of impact on people who use the service (and others, if appropriate to the regulation). This could be a minor, moderate or major impact. Minor impact - people who use the service experienced poor care that had an impact on their health, safety or welfare or there was a risk of this happening. The impact was not significant and the matter could be managed or resolved quickly. Moderate impact - people who use the service experienced poor care that had a significant effect on their health, safety or welfare or there was a risk of this happening. The matter may need to be resolved quickly. Major impact - people who use the service experienced poor care that had a serious current or long term impact on their health, safety and welfare, or there was a risk of this happening. The matter needs to be resolved quickly We decide the most appropriate action to take to ensure that the necessary changes are made. We always follow up to check whether action has been taken to meet the standards. Inspection Report Waterside Care Centre May

18 Glossary of terms we use in this report Essential standard The essential standards of quality and safety are described in our Guidance about compliance: Essential standards of quality and safety. They consist of a significant number of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations These regulations describe the essential standards of quality and safety that people who use health and adult social care services have a right to expect. A full list of the standards can be found within the Guidance about compliance. The 16 essential standards are: Respecting and involving people who use services - Outcome 1 (Regulation 17) Consent to care and treatment - Outcome 2 (Regulation 18) Care and welfare of people who use services - Outcome 4 (Regulation 9) Meeting Nutritional Needs - Outcome 5 (Regulation 14) Cooperating with other providers - Outcome 6 (Regulation 24) Safeguarding people who use services from abuse - Outcome 7 (Regulation 11) Cleanliness and infection control - Outcome 8 (Regulation 12) Management of medicines - Outcome 9 (Regulation 13) Safety and suitability of premises - Outcome 10 (Regulation 15) Safety, availability and suitability of equipment - Outcome 11 (Regulation 16) Requirements relating to workers - Outcome 12 (Regulation 21) Staffing - Outcome 13 (Regulation 22) Supporting Staff - Outcome 14 (Regulation 23) Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10) Complaints - Outcome 17 (Regulation 19) Records - Outcome 21 (Regulation 20) Regulated activity These are prescribed activities related to care and treatment that require registration with CQC. These are set out in legislation, and reflect the services provided. Inspection Report Waterside Care Centre May

19 Glossary of terms we use in this report (continued) (Registered) Provider There are several legal terms relating to the providers of services. These include registered person, service provider and registered manager. The term 'provider' means anyone with a legal responsibility for ensuring that the requirements of the law are carried out. On our website we often refer to providers as a 'service'. Regulations We regulate against the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations Responsive inspection This is carried out at any time in relation to identified concerns. Routine inspection This is planned and could occur at any time. We sometimes describe this as a scheduled inspection. Themed inspection This is targeted to look at specific standards, sectors or types of care. Inspection Report Waterside Care Centre May

20 Contact us Phone: Write to us at: Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Website: Copyright Copyright (2011) 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. Inspection Report Waterside Care Centre May

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