Inspection Report - Care Quality Commission

Inspection Report

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

Vitalise Netley Waterside House

Abbey Hill, Netley Abbey, Southampton, SO31 Tel: 02380453686
5FA
Date of Publication:
Date of Inspection: 08 August 2013 September 2013

We inspected the following standards as part of a routine inspection. This is what we
found:

Consent to care and treatment Met this standard

Care and welfare of people who use services Met this standard

Management of medicines Met this standard

Requirements relating to workers Met this standard

Supporting workers Met this standard

Complaints Met this standard

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Details about this location

Registered Provider Vitalise
Registered Manager
Overview of the Miss Esther Mailley
service
Vitalise Netley Waterside House is part of a national charity
Type of service providing short breaks (respite care) and other services for
Regulated activities people with a physical disability, visually impaired people,
people with dementia, and their carers. They provide respite
care and short breaks in a relaxed, holiday style
environment with a variety of trips and activities. Guests are
supported by trained nurses, care workers and volunteers
who provide companionship and assistance.

Care home service with nursing

Accommodation for persons who require nursing or personal
care
Diagnostic and screening procedures
Treatment of disease, disorder or injury

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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 4

Our judgements for each standard inspected: 6
7
Consent to care and treatment 9
Care and welfare of people who use services 11
Management of medicines 12
Requirements relating to workers 13
Supporting workers 14
Complaints 15
17
About CQC Inspections 19
How we define our judgements
Glossary of terms we use in this report
Contact us

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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 8 August 2013, observed how people were being cared for and talked
with people who use the service. We talked with carers and / or family members, talked
with staff and reviewed information given to us by the provider.

What people told us and what we found

We spoke with eight people using the service who were there for a short term holiday or
respite stay. We also spoke with a family member who was accompanying their relative. At
the time of our visit there were two people using the service who were there on permanent
placements, and we spoke with one of them. They were all happy with the care and
support provided. One said, "It's fine, no complaints". They told us they were satisfied care
and treatment was provided according to their needs and with their consent. They found
staff at the service provided effective, caring support. One said, "The right word for them is
carers, because they care."

We observed the care and support given to people in the communal areas of the home.
We saw that staff and volunteers were friendly and caring, aware of people's needs and
preferences, and responsive to them.

We spoke with eight members of staff, the registered manager and the operations director.
We reviewed records related to people's care. We found people's care needs were
assessed and their care plans reflected their needs. Care and support were planned and
delivered with people's consent. Arrangements were in place for people who were not able
to consent to their support and treatment. People's medication was stored and
administered properly. The provider had effective recruitment procedures and made the
necessary checks before staff and volunteers started work. Staff told us they felt supported
to provide the care required.

You can see our judgements on the front page of this report.

More information about the provider

Please see our website www.cqc.org.uk for more information, including our most recent
judgements against the essential standards. You can contact us using the telephone

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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.

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Our judgements for each standard inspected

Consent to care and treatment Met this standard

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 asked for their consent and the
provider acted in accordance with their wishes. Where people did not have the capacity to
give consent, the provider made appropriate arrangements.

Reasons for our judgement

Before people received any care or treatment they were asked for their consent and the
provider acted in accordance with their wishes. We spoke with eight people who were
using the service at the time of our visit. They told us care and support were provided with
their consent. They were happy they could provide input to their care plans if they wanted
to make a change. They said staff explained what they were doing and asked for
permission before delivering care. Care and treatment were provided in line with people's
wishes.

We observed care provided in the communal areas of the home, and saw staff explaining
what they were doing, guiding and assisting people, and checking they were happy with
interventions. For instance, a volunteer explained that it was time for a person to pick up
their packed lunch before they helped them to move to a different part of the home. Staff
made sure people understood and agreed to their care and support.

We spoke with four members of the care and nursing staff and the registered manager.
They told us most of the people using the service on the day of our visit were able to make
decisions about their care and treatment. If people were not able to consent to their own
care, the service's policy was for people to be accompanied by their own carer, partner or
other family member. The service provided accommodation for accompanying carers.
Arrangements were in place to ensure decisions were made in people's best interests.

The service respected people's wishes in respect to their care and support. One person's
wheelchair was fitted with a safety belt, but they preferred not to have it fastened. This
decision was recorded in their file and they had been asked to sign a form acknowledging
that the belt was left unfastened according to their own preference. Where people
expressed a preference, the provider respected their wishes and acted accordingly.

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Care and welfare of people who use services Met this standard

People should get safe and appropriate care that meets their needs and supports
their rights

Our judgement

The provider was meeting this standard.

People experienced care, treatment and support that met their needs and protected their
rights. Care and treatment were planned and delivered in a way that was intended to
ensure people's safety and welfare.

Reasons for our judgement

People's needs were assessed and care and support were planned and delivered in line
with their individual care plans. We spoke with eight people using the service. They
confirmed care was delivered which was in line with their plans and met their needs. A
family member, who was accompanying their relative as their carer, had been involved in
their assessment and the planning of their care. They told us they were satisfied with the
process and with the support given during their relative's stay.

Staff told us the care plans for people using the service for short term stays were based on
a pre-assessment, usually by telephone with the person or their carer. An initial care plan
was developed from this and discussed with the person when they arrived at the service,
usually on a Saturday. At this stage people were asked to sign the plan to show they
agreed with its content. Plans were reviewed with people the next day, at the mid-stage of
their stay and when they left. This ensured accurate information was kept by the service if
they returned for another stay in the future.

The care plans and other records were maintained on a computer system with printed
extracts available in people's rooms. This meant important information about people's care
was readily available to staff and volunteers. We reviewed four examples of people's care
plans. They were individualised and person-centred. They contained details such as
people's medical history, their mobility needs and communication assessments. People's
preferences with respect to their personal care and how they like to have it delivered were
recorded. Where people's condition meant they needed particular care there were detailed
instructions. Care staff recorded the care and support provided in an "activities of daily
living" log, which was checked each day by a member of the nursing staff. People received
personalised care that met their needs.

Care and support were planned and delivered in a way that was intended to ensure
people's welfare and safety. There was a range of activities and events organised for
people. These included group trips to local tourist attractions and events at the location,
such as a firework display. There were thorough and detailed risk assessments for these
activities which had been formally reviewed in the year before our visit. In addition the duty
manager told us risk assessments for trips were assessed with the trip organiser each time

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the trip was undertaken. People's safety and welfare were protected by risk assessments
which were kept up to date.

People's individual care plans contained action plans for specific risks. These included
steps to ensure people using wheelchairs were accommodated safely in the service's
minibuses, and measures to ensure vulnerable people were accompanied when outside.
Arrangements were in place to enable people to take part in activities safely.

Volunteers were used by the service to assist with activities and provide companionship
and social contact. Paid staff wore colour-coded tops so people could tell nurses and care
workers apart from the volunteers. People using the service confirmed that their personal
and nursing care were only delivered by the appropriate members of staff.

There were arrangements in place to deal with foreseeable emergencies. Fire evacuations
were practised every six months and fire safety equipment was serviced every three
months. Any portable electrical appliances brought in by people using the service were
tested before they were used in the home. If a complete evacuation had to be made, there
were agreements with a nearby care home and local community halls to provide temporary
accommodation. Contingency plans were in place to keep people safe and comfortable in
an emergency.

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Management of medicines Met this standard

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 protected against the risks associated with medicines because the provider
had appropriate arrangements in place to manage medicines. The provider ensured
people could take their medication at the right time.

Reasons for our judgement

Appropriate arrangements were in place in relation to receiving and recording of
medicines. Some people chose to be responsible for administering their own medicines.
They were provided with safe and secure storage in their room. The service kept a record
of the medication they were taking themselves in case the information was needed, for
instance if there was a medical emergency during their stay.

Where the service stored and administered medicines for people, they checked the
quantities of drugs received against the documentation provided and noted any
discrepancies. They wrote their own medicine administration records (MARs) based on the
information they received with the medication. If there was any doubt about people's
medicines the service contacted the person's doctor for clarification. The MARs recorded
the times and doses to be administered. If the drugs were supplied with their own MAR,
this was kept as a reference, but all medicines administered by the service during people's
stays were recorded on their own forms. We reviewed the MARs for two people. They had
both been filled in correctly. Arrangements were made for people to have their medication
at the correct time when participating on trips organised by the service. Processes were
followed to ensure people received their prescribed medication at the correct times.

Medicines were safely administered. A system of red stickers on the MARs was used to
alert nursing staff if there was a risk of medicines being administered wrongly. The stickers
were used, for instance, if people had the same drug, but at different doses on different
days, or if multiple doses were required. Steps were taken to reduce the risk of mistakes
during the administration of medicines.

Suitable arrangements were in place to ensure medicines were kept safely and securely in
locked cabinets. A refrigerator was available for drugs that needed to be kept below room
temperature. There were suitable arrangements for the storing and recording of controlled
drugs. We reviewed the controlled drugs book and saw that entries recording drugs
removed were signed by two members of staff. We checked the number of tablets in the
controlled drugs cabinet and found one instance where the number in store did not match
the record in the book. The corresponding MAR sheet indicated that the drug had in fact
been administered earlier that day but was not recorded in the controlled drug book.

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Controlled drugs records were checked and audited every day, but this check had not yet
taken place on the day of our visit. Arrangements were in place to store medicines safely
and audit controlled drugs. However the provider may find it useful to note that procedures
to record controlled drugs were not always followed.

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Requirements relating to workers Met this standard

People should be cared for by staff who are properly qualified and able to do their
job

Our judgement

The provider was meeting this standard.
People were cared for, or supported by, suitably qualified, skilled and experienced staff.
The provider had effective recruitment processes.

Reasons for our judgement

Appropriate checks were undertaken before staff began work. We looked at the files of
four members of staff and saw that appropriate checks had been undertaken before they
started work. Their files had evidence of two references, proof of identity and right to work
in the UK, and Criminal Records Bureau (CRB) or equivalent checks. The manager told us
CRB checks for staff and volunteers were renewed every three years. Registration details
of staff employed as qualified nurses were checked before they started work. The provider
ensured that people were cared for and supported by employees who were suitable for
work in social care.

Staff records had recently been converted from paper files to computer records. The paper
records had been scanned and organised in folders for each member of staff. The provider
may find it useful to note that the absence of a clear indexing system made it difficult to
find and identify particular records in the folders. One staff member's application form
claimed that they had a relevant qualification. The manager recalled seeing a photocopy of
the certificate in their paper file, but could not locate the scanned version.

There were effective recruitment and selection processes in place. The manager
described their selection process which included an interview with the manager and one
other person. Interviews included a standard set of questions which ensured all candidates
were treated fairly. Interviews were also used to explain any gaps in the candidate's
employment history.

Successful candidates had a six month probation period, during which they completed an
induction and training pack. Induction training included observations by multiple observers
and sign off by the employee and their mentor. We spoke with eight people who used the
service. They all told us staff were competent to provide the care required. One said, "I
would give them all a gold star". The provider's recruitment and selection procedures
resulted in employees who were able to do the job required of them.

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Supporting workers Met this standard

Staff should be properly trained and supervised, and have the chance to develop
and improve their skills

Our judgement

The provider was meeting this standard.

People were cared for by staff who were supported to deliver care and support safely and
to an appropriate standard. Staff attended training to keep their skills and knowledge up to
date.

Reasons for our judgement

We spoke with a total of eight members of staff and volunteers who were all satisfied with
the support they received to deliver people's care. Two care workers confirmed they felt
supported and had received an adequate induction when they started work. One said
there was "a good working atmosphere." Two volunteers felt they received sufficient
guidance and were clear about their responsibilities. People using the service told us they
were satisfied with their care workers' skills and knowledge.

Staff received appropriate professional development. The care workers and nurses we
spoke with told us they received adequate training which enabled them to deliver the
standard of care required. If they needed continuous professional development (CPD) to
maintain their professional certification, they were supported to achieve it.

We checked the training records for four members of staff and found records of courses
completed and qualifications obtained. The absence of both an indexing system for the
computer records and a a training matrix meant it was not possible to obtain a systematic
overview of the training provided. However samples of individual records provided
evidence staff received adequate training to provide the standard of care required.

There was a system of supervisions and annual appraisals, records of which were retained
in staff members' computer files. A sample of records showed that appraisals had been
carried out in the previous twelve months. Supervisions were thematic or responsive,
prompted by a problem, complaint or lapse in performance. Depending on the outcome of
a responsive supervision, it could lead to retraining or additional supervisions. The Head of
Care maintained a matrix which recorded when members of staff had received
supervisions.

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Complaints Met this standard

People should have their complaints listened to and acted on properly

Our judgement

The provider was meeting this standard.
There was a complaints system available. Comments and complaints people made were
responded to appropriately.

Reasons for our judgement

People were made aware of the complaints system. This was provided in a format that met
their needs. Staff told us that during the welcome talk at the start of people's stay they
were informed they could raise any concerns during their stay with the duty manager. The
information pack provided to people using the service contained guidance on how to make
a formal complaint. After their stay people were sent a feedback questionnaire. The
service was receptive to informal and formal complaints.

People had their comments and complaints listened to and acted on, without the fear that
they would be discriminated against for making a complaint. One person using the service
told us they had made a complaint about their personal care which had been dealt with to
their satisfaction. The service had also contacted the person's family to reassure them and
explain what had happened. The person concerned appreciated this, as it meant they did
not have to worry about explaining it to their family.

The operations director told us negative comments in the feedback questionnaires were
raised with the provider's chief executive officer and discussed in management meetings.
If appropriate, lessons learned were shared with all of the provider's locations. For
example, a complaint about uncomfortable rides in a minibus resulted in maintenance to
the suspension of all the minibuses in the provider's fleet.

We reviewed three recent written complaints relating to people's personal care with the
manager. The files showed they had been investigated thoroughly with extracts from
people's daily activities records and statements from staff and volunteers involved.
Appropriate lessons had been learned, for instance with respect to how daily records were
completed if the person involved made a choice to change their agreed plan of care. The
service took complaints seriously and handled them appropriately.

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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
2009. 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 re-
inspect 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.

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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.

Met this standard 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 If the breach of the regulation was more serious, or there
action taken 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.

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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.

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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 2009. 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.

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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 2009.

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.

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Contact us

Phone: 03000 616161

Email: [email protected]

Write to us Care Quality Commission
at: Citygate
Gallowgate
Newcastle upon Tyne
NE1 4PA

Website: www.cqc.org.uk

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.

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