care and social services inspectorate...

Care and Social Services Inspectorate Wales

Care Standards Act 2000

Inspection Report

Amber House

22, Water Street Abergele LL22 7SH

Type of Inspection – Unannounced baseline Date(s) of inspection – 11th and 12th December 2013

Date of publication – 8th March 2014 You may reproduce this report in its entirety. You may not reproduce it in part or in any abridged form and may only quote from it with the consent in writing of Welsh Ministers

Please contact CSSIW National Office for further information Tel: 0300 062 8800

Email: [email protected]

www.cssiw.org.uk

mailto:[email protected]

http://www.cssiw.org.uk/

Care Homes for Older People (GIRPT01E11 0001136987 (20140324)GIRPT01E11 0001136987) Version 8.1 July 2012

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Summary

About the service

Amber House is registered with Care and Social Services Inspectorate Wales (CSSIW) to accommodate twenty four persons over the age of sixty five years, eight of whom may have a diagnosis of dementia. The service currently accommodates eighteen people, eight of whom have a diagnosis of dementia. The home is owned by ‘Larkfield Care Home Limited’ and the responsible individual nominated to represent the company is Mrs Bernice Jaumotte. The registered manager is Mrs Eleri Clark; Mrs Clark has the appropriate management qualification and is registered with the Care Council for Wales. The home is situated in Abergele near to local shops and amenities.

What type of inspection was carried out?

An unannounced baseline inspection was undertaken in response to concerns which were raised by a member of the public on the 2nd December 2013 in respect of recruitment, training, health and safety, infection control measures, staff attitudes, rushed task based care, poor monitoring of nutrition, poor manual handling practices, lack of respect and dignity and lack of positive stimulation and occupation. We (CSSIW) discussed these concerns and asked the responsible individual if she was confident in the manager’s ability and continued fitness, the responsible individual stated that she was. Although the manager was present during both our inspection visits CSSIW has since been informed of her resignation. We viewed the following documentation:

Two care plans and associated risk assessments.

The daily morning and evening records.

Gas and electric safety certificates.

Staff rota dated between 4th November and 29th December 2013.

Staff training matrix focussing on training undertaken between 2012 and 2013.

A repairs and renewal audit dated 2012 – 2013.

A repairs and renewal audit dated 2013 – 2014.

An improvement plan dated 2013.

A contract and invoice in relation to waste disposal dated the 8th May and 1st October 2013 respectively.

We have received four concerns since the last inspection in respect of neglect, someone using the service who had gone missing, medication being left unattended, recruitment procedures and lack of staff presence. In relation to these concerns we spoke with the registered manager on the 26th September 2013 and requested an action plan to prevent staff leaving medication unattended, a timescale of the 30th September was agreed but this information was not received. We discussed this with the responsible individual who told us that staff had provided statements to state the contrary, but these statements were not provided. Other concerns raised were referred to the safeguarding authority, as a consequence an extra member of staff was employed and new documentation was implemented in respect of monitoring assistance with personal care.


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As a consequence of this inspection there have been a number of Protection of Vulnerable Adult (PoVA) referrals made to the local authority in respect of neglect and safeguarding. We toured the premises and viewed the kitchen, kitchen storage areas, some people’s bedrooms and communal areas such as the lounge, dining room, toilets and bathrooms. We spoke with people using the service, staff, stakeholders, the manager and the responsible individual. We undertook observations of interactions between staff and people using the service, the Short Observational Framework for Inspection (SOFI) tool/method was employed to assist with this.

What does the service do well?

The service is expected to operate to at least National Minimum Standards for Care Homes for Older People. We did not evidence anything which exceeded these standards on the days of our inspection visits.

What has improved since the last inspection?

Since the last inspection (29/04/13) some investment has been made to the environment but more is required; The responsible individual told us that she has invested £28,000 to refurbish the ground floor. Despite this we are concerned that there has been such a significant deterioration in the provision of care and services..

What needs to be done to improve the service?

The registered persons must take urgent action in accordance with CSSIW’s handbook in respect of dementia care (2009) with consideration of the findings of this report. In accordance with The Care Homes (Wales) Regulations 2002 we have issued the following non compliance notices:

The Care Homes (Wales) Regulations 2002, 12 (3) in regard to people’s wishes and preferences. We have evidenced that staff do not always support, encourage and assist people when needed. This is a serious issue and we have issued a non compliance notice to the registered persons. The Care Homes (Wales) Regulations 2002, 15 (1) in regard to care planning. It is disappointing to note that despite non compliance notices being issued in the previous inspection report and the registered persons informing us that they had achieved compliance, and providing CSSIW with examples of person centred planning this has not been sustained. We have evidenced that care planning and associated risk assessments must be improved to assist staff in providing responsive and appropriate care. This is a serious issue and we have issued a non compliance notice to the registered persons. The Care Homes (Wales) Regulations 2002, 8 (1) (a) in respect of there being no registered manager for the service from the 9th January 2014. As a result there will be no registered manager managing the service on a daily basis. This is a serious issue and we


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have issued a non compliance notice to the registered persons. The Care Homes (Wales) Regulations 2002, 12 (4) (a) in regard to treating people with respect and dignity. We have evidenced that staff adopt care practices which are not person centred and do not maintain people’s dignity. The fundamentals of care are not always promoted. This is a serious issue and we have issued a non compliance notice to the registered persons. The Care Homes (Wales) Regulations 2002, 16 (n) in relation to activities. Although an activity person is employed she is also employed as a member of care staff. We saw that people were not positively occupied or stimulated during either of our visits with the exception of one fifteen minute activity undertaken with three people with a member of staff. This is a serious issue and we have issued a non compliance notice to the registered persons. The Care Homes (Wales) Regulations 2002, 16 (2) (e), 16 (2) (f), 16 (2) (j) and 16 (2) (k) in respect of cleanliness, unpleasant odours and infection control practices which contravene good practice guidelines. This is a serious issue and we have issued a non compliance notice to the registered persons. The Care Homes (Wales) Regulations 2002, 18 (1) (a) in regard to staffing levels. Staff may not be employed in sufficient numbers or deployed effectively to undertake all the roles to be performed within the home. This is a serious issue and we have issued a non compliance notice to the registered persons. The Care Homes (Wales) Regulations 2002, 18 (1) (i) in relation to staff training. Training in relation to medication administration and management is required as a matter of urgency. There was no evidence on the training matrix to support that other staff have received medication training or that the responsible individual has kept herself up-to-date with care practices. This is a serious issue and we have issued a non compliance notice to the registered persons. The Care Homes (Wales) Regulations 2002, 24 (2) (d), 24 (2) (l) 24 (2) (m)24 (2) (p) in respect of the environment. We saw that investment is required to improve facilities and the environment for people. This is a serious issue and we have issued a non compliance notice to the registered persons. The Care Homes (Wales) Regulations 2002, 25 in relation to monitoring and auditing care and services. Although some monitoring and auditing is undertaken this is not robust to provide sufficient information to action and improve care and services provided by Amber House. This is a serious issue and we have issued a non compliance notice to the registered persons. In accordance with National Minimum Standards for Care Homes for Older People the following good practice recommendations should be considered:

National Minimum Standard 31 and 32 in respect of complaints and safeguarding. Complaints and safeguarding concerns are not always recorded or reported to the safeguarding authority. The staff training matrix illustrates that the registered manager last received this training in respect of safeguarding in October 2011. There was nothing recorded in respect of the responsible individual’s training. Training in respect of


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complaints and safeguarding would be beneficial.


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Quality of life

Overall people looked unclean and unkempt, and their dignity is not always promoted and or maintained. People were left unsupervised for long periods of time with nothing to positively occupy their time for the most part. The responsible individual told us they had employed a full time activity person to undertake this responsibility. Continence is not managed effectively and as a result there is a strong odour of urine which people who live here have to endure. Following the inspection visits the responsible individual asserts that the “odour was caused by the washing machines breaking down on the day of the inspection which was repaired but subsequently broke down again the following day and as a consequence created a temporary smell’. We acknowledge the machines were broken however the strong odour of urine is also due to the poor management of continence. The care regime is not person centred and people are not supported or encouraged to live a fulfilled life. People using the service may feel that their wishes and preferences are not valued. This is because staff do not always encourage and offer people support when needed. We spoke with one person who told us that they were afraid to sleep under the loft hatch in fear that something would fall on them. A mirror was hung beneath/near this loft opening which this person was also afraid of, explaining that they didn’t like mirrors and can’t sleep below one. This person had moved their bed on their own to avoid sleeping in this area but this restricted their access to their sink, wardrobe and drawers. Staff had not assisted this person to re-arrange their room to their liking. Their curtains were closed shut; they explained that they did not want to open them because there were no nets or blinds hung, and that they felt uncomfortable with them open because workmen were working outside opposite their window. This person told us they had got used to their room and were happy with it. We spoke with staff and the responsible individual about this who told us this person was very private and didn’t like people in their room; this was reflected in their care plan. However we would question this, given that we spent considerable time chatting with this person during both our visits and this person was happy to talk with us, show us their room, personal belongings and speak to us about their concerns and their life. One person we spoke with told us they were happy living here. People using the service cannot always expect an appropriate response to their needs. This is because care plans are not easily attainable; they are accessed via a key coded door and not all staff know the key code. The care plans we viewed did not accurately reflect all needs and contained conflicting information. Care plans were not comprehensive; they did not contain sufficient detail to instruct staff on how to deliver appropriate and responsive care in respect of all needs. We observed that staff did not follow the care plan in respect of one person and their meals. Visiting health professionals told us that more information had been included in the care plans but that the recording of nutrition, diet and fluids needed to be improved and that referrals were not being made to the dietician, in respect of this. A care plan we viewed highlighted good practice in respect of contacting members of the multi disciplinary team for advice and treatment, it also showed that an imminent appointment was due to review this person’s treatment regime, this illustrates members of the multi-disciplinary team are accessed. Effective care planning is essential to ensure that people receive appropriate and responsive care to meet their individual care needs, thus identifying their strengths as well as their deficits to promote enhanced well being.


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People using the service cannot expect staff to provide care in a dignified manner or support them properly with their personal care. This is because staff adopt task based communal care practices. We saw toiletries and unlabelled garments in communal bathrooms and in the laundry room. We spoke with a member of staff who did not know if a pair of trousers belonged to a person she was getting them for. We saw people wearing clothes which were unclean, creased and of poor condition. For example one person wore a cardigan which had ripped up the side, and this was held together with safety pins. Following the inspection visit the responsible individual informed us that they have repeatedly tried to have relatives provide new clothing, but we did not see evidence of this and that the responsibility for providing new clothing lies with the social workers. People looked unkempt, we saw some people who were unshaven, and some people had food debris around their mouth and on their clothes, people were not assisted to freshen up following their meals and remained unclean for the duration of the day. One person’s hair looked matted. When we did observe staff interact with people their approach was kind but the care ethos is regimented and institutionalised, this may be attributed to staff changes but this practice has not been challenged by the manager.


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Quality of staffing

Overall staff have received both mandatory and specialist training which was undertaken between 2012 and 2013. However staff do not always implement this knowledge. The fundamentals of care must be advocated at all times to ensure staff adopt best care practices so that people receive care in a dignified manner, as we have evidenced that this is not always the reality. The responsible individual told us that there has been an increase in the number of staff who have left employment. Following the inspection the responsible individual told us that ‘there have only been three members of staff leave within the twelve month period prior to the inspection’. However information provided by the registered persons through the Self Assessment of Service form, which was received on the 31st May 2013 states that seven members of staff have left employment and that eight people have been employed. This has an impact on care delivery as the care given is inconsistent and continuity of care is affected. People using the service cannot always expect staff to respond appropriately or positively to their needs. This is because staff have an attitude of apathy as they do not take ownership when something needs addressing. For example when people’s clothes need replacing or repairing. We saw one person sitting in the lounge with a mug of tea but they were sleeping as a result their mug had tipped and the tea was ready to spill out over them. Two members of staff came into this room between 7.30am and 7.45am but did not intervene to prevent a potential scald. This means people could be at risk of receiving a burn. People using the service cannot expect to be properly supervised or that staff will sit and spend quality time with them. Staff may not be employed in sufficient numbers or deployed effectively to ensure all roles within the home are undertaken efficiently. Documentation we viewed showed that one person was employed as housekeeper, the home is large and offers a laundry service therefore this may be inadequate. From documentation provided it appears this person has left employment and it is not clear if this position has since been re-filled. The improvement plan illustrates that ‘extra staff hours have been allocated within the house keeping team to deal with this task’. We undertook observations and saw that people were left to sit for long periods of time unsupervised, for three, four hour periods. We did not see staff presence with the exception of meal time. We saw that some people slept and dozed intermittently, and some people stared at nothing in particular; as a consequence people were withdrawn and passive. There has been a high staff turnover which may affect care practices and consistency. People using the service cannot expect that staff will administer their medication safely and in accordance with good practice guidelines. This is because staff do not adhere to the home’s medication policy or the Royal Pharmaceutical Society Guidelines. We observed staff practice in respect of medication administration which contravened guidelines. For example staff did not use the medication trolley, they walked through the home and administered medication in an open pot, and they did not use the Medication Administration Record (MAR chart) or wait to observe that two people took their medication. We discussed medication administration and management with the registered persons who told us that they audit this aspect of care and that a pharmacist inspector has recently undertaken an inspection. We requested copies of the reports but these were not provided. We liaised with the pharmacist inspector from Betsy Cadwaladr University Health Board (BCUHB) who informed us that they had not inspected the service since January 2012 but that they were recently requested (02/01/14) by the local


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authority to undertake a medication management assessment. The assessment highlighted areas for improvement. According to the staff training matrix one person has received training in respect of this and this is the manager who has resigned her position. Given these concerns, persons must be identified to undertake this responsibility and receive accredited training as a matter of urgency. Following the inspection visits the responsible individual informed us that accredited medication training was undertaken in January 2013 and will be refreshed in January 2014. However we observed that staff did not implement this training to ensure their practice was safe.


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Quality of leadership and management

Overall the service and care provided has deteriorated since the last inspection. There is no clear leadership and management. The registered persons are disorganised for example there is no order in the manager’s office, there were numerous large piles of paperwork, covering work surfaces and the floor. We were told in the last inspection (April 2013) this was because the office was being re-organised; however it remains in the same state. Following the inspection visits the responsible individual informed us that ‘leadership and management is also provided by the responsible individual who is registered with the Care Council for Wales as a manager. The home has changed its operational name but documentation with the home’s previous name is still being used. It was evident investment is still needed to upgrade and refurbish the home. There are some monitoring and auditing systems in place but these are not robust or actioned as a consequence people do not experience living in an improving service. The responsible individual told us that she has appointed a person to act as deputy manager and has registered with an employment agency in respect of appointing an acting manager since the manager has resigned. The responsible individual provided us with an improvement plan. People using the service cannot expect appropriate measures to be taken to improve the care and services provided by Amber House. This is because although there are some monitoring and auditing systems in place they do not provide sufficient information to develop the service and improve care practices. Visiting professionals informed us that care planning had improved but that more work was required to ensure they were person centred and reflected current care needs. We looked at accident/incident reports and noted that between the 7th August and the 6th October 2013 there have been eleven falls, which were all unwitnessed and occurred in communal areas, the dining room and the corridor, two entries did not record the location. The responsible individual confirmed that falls are not audited but given the frequency of falls this is imperative to manage and reduce falls occurring within the home. We observed one person descending down the main stairs backwards, we liaised with visiting professionals who had case tracked this person’s care plan, it was identified this person was a high risk of falls but we were told it was difficult to establish how this had been determined. The registered persons told us they monitor and audit medication, the kitchen, stock, care plans, the environment/maintenance but given the concerns identified during this inspection visit it is evident that improvements are needed in these areas. People using the service cannot always be confident that complaints and safeguarding concerns will be effectively managed. This is because the recording and the lack of recording in respect of this caused concern. There is a complaints template available but there were no complaints recorded, the registered persons told us they never receive complaints. During the last inspection (April 2013) systems were in place to manage complaints so it is disappointing that this aspect of management has deteriorated. We viewed incident reports, no outcomes had been recorded and some of the information documented caused concern due to the nature of what was recorded. These incidents involved two people who have a diagnosis of dementia, the registered persons were aware of the issues which should have been referred to the safeguarding authority but they weren’t. Since the inspection visit several Protection of Vulnerable Adult (PoVA) referrals have been made to the safeguarding authority in respect of neglect and abuse between two people using the service. These are currently under investigation.


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Quality of environment

Overall some investment has been made to improve the service but further investment is required. We saw new cushion flooring had been laid to the ground floor and some people’s bedrooms. We saw that some rooms had been re-decorated and second hand furniture such as chairs had been purchased. The responsible individual told us that they had spent considerable monies to improve the standards of the service, but it is evident further investment is needed. Following the inspection visit the responsible individual informed us that five of the six toilets within the service have been redecorated in 2013. A prioritised maintenance programme is in place which identifies domestic and refurbishment works to be undertaken during 2014. Upon entering the home there is a noticeable odour of urine which emanates throughout. The home is unclean, for example we saw three beds which had been made up by staff but they were stained with faeces. This has been raised previously following the monitoring visit by visiting professionals. We saw crockery which was stained, unclean and stained carpets, areas were disorganised including outside storage. We could not see the pictorial signage which was displayed during the last visit (April 2013) to promote independence and assist people in finding their own way around. There was no attention to detail and items such as bedding and tableware are of poor quality. We saw that food stocks were low but a delivery was due later in the day. People using the service cannot expect to live in an environment which promotes their well being. This is because the home is unclean with offensive odours throughout. We saw furniture, bedding and towels, which were not adequate. We saw a supply of new linen which was stored in the manager’s office but she was unaware that linen in use needed replacing, she told us that she was reliant upon staff to ask for new sheets and pillowcases. Carpets, bed linen and crockery were unclean and of poor quality. Some items of furniture were broken. The television in one lounge did not work so people who like to sit in this lounge have nothing to watch. People cannot expect staff to follow infection control practices in accordance with good practice guidelines or the home’s policy. This is because protective clothing is not easily accessible and staff do not implement the training they have received. Nine staff have undertaken infection control training this year. Staff have not implemented good practice in respect of the laundry service, assisting people with personal care, and the environment. We saw that protective clothing, paper towels and liquid soap were not readily available in communal bathrooms and toilets. With the exception of one member of night care staff (wore gloves) we did not see staff using protective clothing. The laundry service was disorganised and staff did not adhere to good practice. We heard a member of staff ask another member of staff which mop was used to clean the dining room floor as they did not know. There is no yellow clinical waste bag system in place to dispose of infectious soiled items, we acknowledge the current system in place has been agreed with a contractor however there must be a safe system in place to dispose of infected waste products such as infectious incontinence products and dressings. In the kitchen some equipment such as the fryer needed cleaning, drawers were missing and there was no waste receptacle. People using the service cannot be confident that up-to-date safety checks are carried out in respect of utilities. This is because we detected an odour of gas and saw electrical plugs and sockets with warning signs saying ‘not to use’. We requested the certificates


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during the inspection and we e-mailed the responsible individual on the 13th December 2013 in respect of this. Copies were provided on the 13th December 2013 but these were out of date. We e-mailed the responsible individual again to request up-to-date copies and also asked her to provide them during a meeting which was held on the 8th January 2014 but to date we have not received them. We received a response to the draft inspection report on 12th February 2014 advising that up-to-date gas and electrical safety certificates were attached with the response but we did not received these.


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Care Standards Act 2000

Non Compliance Notice Care homes for older people

This notice sets out where your service is not compliant with the regulations. You, as the

registered person, are required to take action to ensure compliance is achieved in the timescales specified.

The issuing of this notice is a serious matter. Failure to achieve compliance will

result in CSSIW taking action in line with its enforcement policy.

Further advice and information is available on CSSIW’s website

www.cssiw.org.uk

Amber House

22, Water Street Abergele LL22 7SH

Date of publication – 8th March 2014

You may reproduce this notice in its entirety. You may not reproduce it in part or in any abridged form and may only quote from it with the consent in writing of Welsh Ministers

Please contact CSSIW National Office for further information Tel: 0300 062 8800

Email: [email protected]

http://www.cssiw.org.uk/

mailto:[email protected]


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North Wales Region Government Offices

Sarn Mynach Llandudno Junction

Conwy LL31 9RZ

03000625609 03000625030

Home: Amber House

Contact telephone number: 01745 833102

Registered provider: Larkfield Care Home Ltd

Registered manager: Eleri Mair Clark

Number of places: 24

Category: Care Home - Older Adults

Dates of this inspection from: to:

Dates of other relevant contact since last report:

Date of previous report publication: 31st May 2013

Inspected by: Marie Tait and Pat Carragher


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Quality of life

Non compliance identified at this inspection and action to be taken

Action to be taken Timescale for completion

Regulation number

The registered persons must ensure that staff considers people’s wishes and preferences in respect of their activities of daily living.

12/02/14 12 (3)

The registered persons must ensure that care plans are person centred, unambiguous, contain sufficient detail to instruct staff to deliver responsive and appropriate care and consider all care needs.

12/02/14 15 (1)

The registered persons must ensure staff respect and maintain people’s dignity at all times. Training in respect of this must be undertaken to ensure the fundamentals of care are advocated at all times.

12/02/14 12 (4) (a)

The service is not compliant with The Care Homes (Wales) Regulations 2002, 12 (3). This is because staff do not support people with aspects of their daily living with consideration of their wishes and preferences. The evidence includes:

We spoke with one person using the service who was a tablet controlled diabetic, they told us they had not had a cup of tea, they said “just don’t grumble don’t get anywhere, they’re busy”. They had their own juice available. This person was not offered a hot drink until they came down to the dining room for their breakfast, this was at 9.22am. We saw four people sitting in the dining room upon our arrival at 7.30am; we saw that people did not have a drink until after 8.30am following the staff handover with the exception of one person who was sitting in the lounge.

We saw that staff had set the dining tables ready for tea. Mugs and cups were placed and some contained sugar. This is indicative of institutionalised care practice as an assumption is made by staff that people will always sit in the same seat to dine.

One person told us that they had asked staff to get them some wool for knitting they said staff told them that they couldn’t get it.

One person told us you have to ask staff to go out but if it’s cold outside and you’re shivering or have a cold staff won’t let you go out.

One person told us that they used to go to chapel all the time. We asked if they were supported by staff to go they said “no”. We asked if they had asked staff for support they told us they now go somewhere local instead.

One person told us they were vegetarian, we asked if their needs were catered for. They told that they were and that staff knew what they liked to eat. They gave an example of the forthcoming Christmas lunch explaining that they would just eat the vegetables. This is not appropriate and illustrates a lack of provision around this person’s dietary needs.


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We saw that one person had a worn threadbare cover (shawl) which was practically split in two halves. There were no other blankets or duvet available should this person have required one for warmth.

We saw that one person was upset and crying but staff did not offer any support or reassurance. This was only done when staff noticed us intervene to ask this person what was wrong.

During the teatime period we saw that one person wanted a cup of tea, staff told them ‘but you have juice’. Staff did get this person a cup of tea but we feel that this was done due to our presence.

One person who was registered blind told us they couldn’t get out and that the last time they’d been able to visit their relative was in the summer.

The evidence indicates that staff do not always support people or meet their needs effectively in aspects of their daily living. The impact for people using the service is people have no real choice about some aspects of their daily living. People may become resigned to the culture of the home and staff practices and reside themselves to not having a choice. The service is not compliant with The Care Homes (Wales) Regulations 2002, 15 (1). This is because care plans do not always contain sufficient information to instruct staff on how to deliver appropriate and responsive care. The evidence includes:

We viewed two care plans and associated risk assessments and identified the following.

o This person was assessed under the heading ‘mental status’ as having a learning disability but no other information was avaialble.

o In respect of foot care it was recorded “no problems at present” but we saw that this person had a dressing in place.

o In the section skin integrity it was recorded “fine at present on E45 for itching and has cellulitis on left arm”. This is contradictory and it was not clear if this person was receiving anti biotic therapy or other treatment for this.

o In the medication section it was recorded “none at present” but then stated “on anti biotics due to an infection in right arm”, dated 8th August 2013.

o In respect of mobility it was recorded “poor mobility shuffles, fallen in the past, hoisting into bed x 2”.

o The falls risk assessment had not been reviewed since 13th August 2013 and it was recorded “no change” as opposed to why the care plan remained effective.

o In the section ‘identified risks’ it was recorded “risk of falls”. o In the section ‘identified risks’ regarding continence it was recorded “uses

pads throughout the day needs assistance and commode at night”. There was a noticable odour of urine in this vicinity.

o There was no care plan available in respect of continence management, tissue viability, communication and it was not recorded that this person had a visual impairment, they are blind in one eye and the other eye is deteriorating.

o It was recorded “X needs assistance with oral hygiene at least twice a day”, it was not clear how this support should be provided and it was also recorded “doesn’t have teeth”.

o In respect of nutrition in the comments section it was recorded “ensure X has food cut up and plate guard”. The outcome of the assessment was “ensure X is safe and has all they need”, this was dated 19/05/11. We saw during the tea time meal that this person was given a sandwich to eat.


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o Care plans must be reviewed on a monthly basis or as care needs change, they were last reviewed in October 2013.

o In respect of positive occupation and stimulation it was recorded “colour in books all day”. We saw that this person had books on their table but we did not see them at any point during either of our visits using them.

o It was recorded “does not ring the bell staff to check regularly”, but we did not observe staff doing this.

o The daily routine for both day and night are recorded in a book. Information is limited and repetitive for example an entry dated 07/12/13 recorded “up already, dressed, assisted with meal, toilet no problem”. An entry dated 08/12/13 recorded “X up and dressed at start of shift X has been assisted to attend meals, eating fairly well. X has spent day in the lounge watching TV”. There is no information in the care plan to instruct staff to asist this person with their meals, if this is the reality, the care plan may need to be updated to reflect this need. Also we would question if there was a need around nutritional intake given it was recorded “eaten fairly well” as it is not clear how much has been consumed.

o In another care plan it was recorded “personal care not resistive or aggressive” but it was not clear what this person was able to do for themselves or what support they required.

o In another person’s care plan it was identified that they required encouragement and assistance with personal care. That they declined baths and won’t allow anyone to see their feet. It was also identified that this person is independent and a private person. There was no information recorded to assist staff on how to approach this aspect of care to encourage good personal hygiene. It would be difficult for this person to wash on their own as their sink was not easily accessible,

A non compliance notice was issued in the last inspection report in respect of improving care plans, we have identified improvments are still required.

Visiting health professionals told us that the care plans they viewed had improved as they contained more information than previously seen but that they still required further improvement to ensure they reflected current care needs and gave clear instruction to staff on providing care.

The evidence indicates that care plans do not always reflect people’s needs, they contain information which is conflicting and they do not instruct staff on how to provide responsive and appropriate care. The impact for people using the service is they may not receive appropriate care or support to meet their individual needs.

The service is not compliant with The Care Homes (Wales) Regulations 2002, 12 (4) (a). This is because staff adopt task based communal care practices and do not maintain people’s privacy and dignity. The evidence includes:

We saw one person who wore a jumper which was ripped around the neck.

One person was walking around with their trousers undone and they were unclean.

One person had been admitted to hospital but their hearing aid had been left behind which they may have needed. Urine had dried in the urine receptacle which created an odour.

In the downstairs communal bathroom/toilet there was a trolley with three shelves which stored a pile of worn towels, these were not individually identifiable. This indicates institutionalised communal care practice which is not a person centred approach to care. There were no paper towels or protective clothing available such


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as gloves and aprons. There was a basket which contained razor blades and shaving foam. There was a sign instructing staff not to leave toiletries in the bathroom because this practice increases the risk of cross contamination.

In a communal toilet there was a sign which read “Residents please do not take toilet rolls out of toilets, thank you”. There was another sign which read “Ladies please put your used pads in this bin, thank you”.

There was no protective clothing available for staff to use in the communal bathrooms, toilets or people’s rooms. A supply is kept in a designated room but the door is locked.

We observed a staff handover which was undertaken in the dining room. Four people using the service were sat in the room. Staff reported on the night shift events and comments we heard included: “X slept in chair, requested to sleep in chair”, “X slept well can’t find care plan” and “X buzzing for an hour and a half then settled”. It is not appropriate to discuss people in front of other people using the service; it does not maintain people’s dignity or privacy.

We saw a visiting professional undertaking and discussing care in the lounge in front of other people using the service.

The evidence indicates that staff deliver rushed task based care and adopt communal care practices when assisting people with their personal care. The impact for people using the service is people are at risk of infection because toiletries are used for more than one person rather than individualised use. People may feel their privacy and dignity is not maintained, that care is rushed, they may not have pride in their appearance and they may not feel clean.


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Quality of staffing



Regulation number

The registered persons must ensure staff are employed in sufficient numbers to effectively undertake all the roles to be performed within the service.

12/02/14 18 (1) (a)

The registered persons must ensure that people are positively occupied and stimulated with consideration of their individual abilities and interests. Advice and guidance must be sought in respect of this.

12/02/14 16 (2) (n)

The registered persons must ensure staff receive appropriate training to perform their roles within the service. Accredited medication training is required as a matter of urgency to ensure staff practice is in accordance with the Royal Pharmaceutical Society Guidelines.

12/02/14 18 (1) (c) [i]

The service is not compliant with The Care Homes (Wales) Regulations 2002, 18 (1) (a). This is because staff may not be employed in sufficient numbers and or deployed effectively to undertake all the roles to be performed within the service. The evidence includes:

The service is registered to accommodate twenty four older persons, eight of whom can have a diagnosis of dementia. The service currently accommodates eighteen people which include eight people who have a formal diagnosis of dementia. The service is large and covers two floors. On a typical day shift the manager is supernumerary, two members of staff work between 8.00 and 20.00, one member of staff works between 8.00 and 14.00, and one member of staff works between 14.00 and 20.00. Two members of staff work the night shift between 20.00 and 8.00. Laundry is not outsourced which creates an extra service provision for staff.

We did not see staff presence with the exception of meal time.

There has been a considerable turn over of staff which may have an impact on the quality of care and services provided.

The responsible individual told us that staff morale is low and that staff are leaving the service.

We observed that people were left to sit for long periods of time unsupervised.

We saw that people slept, dozed intermittently, stared at nothing in particular and as a result became withdrawn and passive.

We did not see staff sit and spend one to one quality time with people. With the exception of our second visit to the home. We saw the activity person sit and read questions from a book (quiz) with three people this was for fifteen minutes. This is not contradictory as it is not appropriate to provide positive stimulation/activities for


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solely three people using the service. We would expect that staff have time to sit and spend quality time with people not necessarily providing care support.

We saw evidence of communal care practices in respect of assisting people with their personal care; we saw personal toiletries which were not individually identifiable and clothes which were not labelled.

We saw that care was institutionalised; staff had put out stained mugs and cups with sugar already in them. We also saw task orientated care practices for example the meal time experience. This indicates that staff were expecting people to sit in the same place.

We observed that the meal time experience for people had deteriorated it was like a waitress service event, it was task based. Staff were focussed on serving meals as opposed to creating a relaxed, fun and sociable ambience.

One person using the service told us staff were busy.

One person using the service had been incontinent on a chair in lounge; staff were not in the vicinity to notice this and clean it. Later we saw another person sitting in the same chair. The chair had not been cleaned or removed.

The home was unclean with debris and stained flooring, unclean bed linen, and unpleasant odours.

There did not seem to be designated laundry person to undertake this responsibility. The laundry room was unclean, disorganised and there was no evidence that infection control measures were adhered to or in place.

There are a substantial number of unwitnessed falls occurring in the home and from the ones we viewed these occurred in communal areas such as the lounge and dining room, two did not record the location.

The evidence indicates that staff are not employed in sufficient numbers to properly supervise people, assist people with their personal hygiene and effectively undertake all the roles to be performed within the service. The impact for people using the service is people may be not see staff presence to ask for assistance. People may feel guilty for asking for help because the impression given is that staff are busy. Ultimately people may receive poor quality care and services. The service is not compliant with The Care Homes (Wales) Regulations 2002, 16 (n). This is because although there is a full time activity person employed, their hours in respect of providing activities are allocated between 14.00 and 17.00. The evidence includes:

Evidence from the last inspection report (April 2013) which identified that hours allocated for activities were not protected as the activity person also assisted other staff with care delivery. The activity person worked three afternoons per week; the activity board we viewed on this occasion suggests that this is still the case.

We saw the activity person during both our visits, the first visit we saw that she was busy displaying the Christmas decorations but she did not involve people using the service. During our second visit she arrived nearing the tea time period but according to the notice board activities were not scheduled for today. She sat with a small group of people (3) for fifteen minutes in the lounge asking quiz questions but she didn’t look comfortable doing this and she spoke quietly. For example the activity person did not encourage or include other people to partake and or engage effectively with the three people whom she was attempting to positively occupy and stimulate.

We saw people were left to sit unsupervised for long periods of time; as a consequence people slept, dozed and became withdrawn and passive.

The television in the lounge had a chair pushed up in front of it, in the last inspection (April 2013) we reported that this television was not working properly.


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We undertook observations and saw that people were left to sit unsupervised for long periods of time. We saw one person who had books to read but these were not within their reach and a table was pushed up in front of them which restricted their movement.

The evidence indicates that people are bored with nothing to do for the most part. The impact for people using the service is their day may be long, and they may be bored. People will become withdrawn and passive which may even lead to people becoming depressed.

The service is not compliant with The Care Homes (Wales) Regulations 2002, 18 (1) (i). This is because training in respect of medication and dignity in care has not been undertaken with the exception of the manager (medication). The responsible individual informed us that some staff had undertaken medication training in January 2013 and that refresher training was due in January 2014. It is imperative that the fundamentals of care are advocated at all times. The evidence includes:

In the last inspection report (April 2013) we reported that staff lacked confidence providing care for people with more complex and challenging needs. We saw that staff do not support or encourage people with a diagnosis of dementia with some aspects of activities of their daily living.

We viewed a staff training matrix which illustrated that only the manager has undertaken training in respect of medication administration and management.

The manager officially leaves the service on the 9th January 2014 and therefore a designated trained person will have to be identified to administer medication.

We observed staff practices which contravened medication administration good practice guidelines. For example we saw medication floating in someone’s beaker of water and we saw staff take medication from the pot with their fingers, place it on their hand and give it to someone.

We have liaised with the local authority pharmacist inspector who visited the home on the 2nd January 2014 and identified areas for improvement which includes, two staff must witness and record medication on the Medication Administration Record (MAR chart), the administration of ‘as and when required’ medication was being given on a regular basis, this should be reviewed and the re-ordering of stock which was not required.

The staff training matrix provided does not illustrate that care staff have received training in respect of medication administration and management. However following the inspection visit the responsible individual told us some staff had received this in January 2013.

The staff training matrix does not illustrate that dignity in care training has been undertaken. Given the concerns identified this may be beneficial for staff and will improve the care people receive.

We saw that people receive task orientated care which does not maintain their dignity. For example the meal time experience is rushed and like a waitress service event.

We saw evidence of communal care practices in respect of assisting people with their personal care. For example in communal bathrooms we saw toiletries which were not individually identifiable.

With the exception of one member of staff who wore protective gloves we did not see staff wearing protective clothing, in accordance with infection control measures.

The evidence indicates that further training is required to promote the fundamentals of person centred care and ensure safe medication practices.


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The impact for people using the service is they may receive medication which is not theirs or in a safe manner because staff do not adhere to good practice guidelines. People may feel they have little choice in how they are cared for because staff do not provide the fundamentals of care in a person centred manner. People are at potential risk of infection due to infection control practices adopted by staff which contravenes good practice guidelines.


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Quality of leadership and management



Regulation number

The registered persons must ensure there are robust monitoring and auditing systems in place to enable them to identify trends, good practice, improvements and actions to be taken to improve the care and services provided by Amber House.

12/02/14 25 (1)

The registered provider must appoint an acting manager with the appropriate qualifications who is registered with the Care Council for Wales.

12/02/14 8 (1) (a)

The service is not compliant with The Care Homes (Wales) Regulations 2002, 25 (1). This is because although there are some monitoring and auditing systems in place they do not provide the registered persons with sufficient information to identify trends, good practice and make improvements to the care and services provided by Amber House. The evidence includes:

There are a substantial number of falls occurring in the home. Between the 7 th August and the 6th October 2013, there have been eleven falls, which were all unwitnessed and occurred in communal areas, the dining room and the corridor; two entries did not record the location.

We spoke with the registered persons who told us they do not audit falls.

Some people using the service have been assessed as a high risk of experiencing falls.

The registered persons told us that they monitor and audit medication, the kitchen, stock, care plans, the environment/maintenance but given the findings of this inspection it is evident this is not robust and or findings not actioned.

The evidence indicates that monitoring and auditing systems need to be improved to develop the care and services by Amber House. The impact for people using the service is people will not benefit from living in an improving service. The service is not compliant with The Care Homes (Wales) Regulations 2002, 8 (1) (a). This is because the manager officially resigned from her post on the 9 th January 2014. The evidence includes:

The responsible individual informed us that the manager had been on leave due to health reasons and work pressures but was returning on the 12th December 2013 on a phased return, to work Monday to Thursday between 10.00 and 14.00.

We saw during both our visits the manager was present at the service for a short period of time.

We received a letter on the 18th December 2013 informing us that the registered manager resigned her position on the 12th December 2013.


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We issued the appropriate documentation on the 19th December 2013 to formally record the de-registration of the registered manager.

The responsible individual has appointed someone as deputy manager with the possibility of them becoming an acting manager depending upon their performance during this interim period but this person does not hold the appropriate management qualification and is not registered with the Care Council for Wales. Therefore this is not a suitable appointment.

The evidence indicates there is no one with the appropriate management experience as from the 9th January 2014 to effectively manage the service. The impact for people using the service is there will be no clear leadership or management and the service may not be managed effectively on a daily basis.


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Quality of environment



Regulation number

The registered persons must ensure that the home is clean, and all areas are reasonably decorated. There must be adequate storage for the purposes of the service and for people using the service. Utilities must be safety checked and the up-to-date safety certificates in respect of these provided to CSSIW.

12/02/14 24 (2) (d) 24 (2) (l) 24 (2) (m) 24 (2) (p)

The registered persons must ensure that the laundry facilities provided are in good working order. If not contingency plans must be in place to ensure that all laundry is clean and ironed. Infection control guidelines must be implemented and adhered to. Suitable kitchen facilities and equipment must be provided such as crockery and cooking utensils. The home must be kept free from offensive odours.

12/02/14 16 (2) (e) 16 (2) (f) 16 (2) (j) 16 (2) (k)

The service is not compliant with The Care Homes (Wales) Regulations 2002, 24 (2) (d), 24 (2) (l), 24 (2) (m) and 24 (2) (p). This is because investment is required to improve the standards of the environment in which people live and unpleasant odours emanate throughout the home. The evidence includes:

Upon entering the home we noted that the carpet was unclean, there was a Zimmer frame stored in this area and there was a strong odour of urine.

In one person’s room we saw that the curtains were off their hooks in parts, there was a stain on their cabinet. We saw inappropriate storage on top of their wardrobe which is a potential risk of injury. Nails were protruding from the wall and there was a strong odour of urine in this room.

In one person’s room we saw that the carpet was stained, the curtains were hanging from the hooks in parts, there was a stain in the bottom of the wardrobe, which looked like a urine stain. A mat had been strategically placed to cover a stain on the cabinet. There was a strong odour of urine in this room. We passed this room later and noted that the window had been opened in an attempt to eradicate the smell.

In one person’s room we saw there was a stain by their bed on the floor, picture hooks were protruding from the wall, wall paper was missing in parts. The bedside lamp did not work. The radiator cover had not been painted and was stained. There was a strong odour of urine in this room. We passed this room later and noted that the window had been opened in an attempt to eradicate the smell.


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In one person’s room there was no working light.

In one person’s room we saw that their clothes were trapped in the wardrobe door. There was a plug in heater in this room which implies the central heating radiator was not working. The chair was stained. The radiator cover was not painted and it was stained. We saw inappropriate storage of a lamp, shade and a bulb stored on top of their wardrobe. A call light was left in the wall. The curtains were off their hooks in parts, picture hooks were protruding from the wall and the lighting was not adequate.

One person’s room was locked; the responsible individual and staff told us this was their preference. This person told us they did not like people coming through the door and that they had a key but that it had vanished. There was a reinforced window which looked out onto the corridor but this was not covered from inside the room. The curtains on the main window were off the hooks in parts and were very long; they had been scrunched up and placed on top of the radiator. The pillow case on the bed was unclean. There was a thread bare blanket (which was in effect a shawl) which was almost in two halves, this was used to cover the bed and was the only means of warmth for this person, we asked if they were warm enough and they told us it wasn’t cold yet. This person used a bed cover which they had folded and placed in the pillow case to plump up their pillow. The bed’s base springs were protruding. There was no light to assist this person in accessing the en-suite facilities this is a potential falls risk, there was also no toilet paper available. We spoke with staff about this who said they would address this but when we checked the next day this had not been done. We discussed this with the responsible individual who explained there was a problem with the electrics and the light couldn’t be repaired. This person was offered alternative accommodation which they agreed to use. Following the inspection an improvement plan was received which stated that the light should always be left on in the stair section but this is the light that was broke and that this person has a key to their room ensuring their privacy but this person told us their key had vanished.

In another person’s room there was a strong odour of urine.

In another person’s room there was no radiator protective cover and the rad was hot to touch, cylinder foam covered some of the rad. The chair arm was worn. This room had a door which was a fire exit, the person using this room told us they lock their door and have a key. This is a fire safety risk and must be addressed. Following the inspection visit the responsible individual informed us that this had been agreed with the fire authority but evidence of this was not provided.

The door leading to one person’s room had not been painted and it was locked.

In one person’s room there was an odour of urine, the light was not working. The radiator cover was not painted and the door did not close properly.

In one person’s room there was an odour of urine. The walls were damaged in parts which needed re-papering. There was a suitcase stored on top of the wardrobe which is a potential risk.

Some people’s bedroom doors are heavy and slam shut creating a loud bang. This is a potential risk of injury.

In one person’s room we saw that the floor was unclean, there was inappropriate storage. Suitcases, an empty shoe box and sheets were stored on top of the wardrobe. The table was unclean and the pressure relieving cushion was also unclean.

In one person’s room the radiator was not working, this person had a blanket around them but they felt cold to touch. This person was not well and was on a course of anti biotics.

In one person’s room we noted a strong smell of urine.


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In another person’s room wire was trailing from the television, this is a potential hazard.

In one person’s room we saw a cable leading from the wall to the lamp, this is a potential hazard. A heater was stored in the wardrobe.

In one person’s room urine had dried in a urine receptacle which created an odour. This room was empty but their belongings which they may have needed such as their hearing aid had been left behind. No explanation was provided by the registered persons at the time of the inspection visit but the responsible individual informed us following the inspection visit that the hearing aid was not sent with them into hospital because they “refuse to wear the hearing aid and sending it to hospital would be likely to result in the aid being lost”.

In a bedroom which is currently used by staff the pipework is exposed.

In one room we saw five chairs stored and the lighting was not adequate.

In one communal toilet the toilet brush and holder was unclean. The extractor was unclean, there was no light shade and paper towels were not available.

In a communal toilet there were no paper towels available for people to use to dry their hands. There was no light shade and the room needed re-decorating.

A storage cupboard next to the toilet contained worn and frayed towels.

In a communal bathroom there was storage on shelving which consisted of hoist equipment and shaving foam in a basket. There was a broken waste receptacle with used paper towels in it.

In one communal toilet the pipework needed repainting and there was no sink for people to wash their hands.

In a lady’s double communal toilet there were no paper towels available. There was a strong odour of urine in this area.

One communal bathroom was nailed shut and is out of commission.

Radiators in some parts of the home were unprotected and very hot to touch. We saw one person use a hot radiator to support themself to get up from their chair.

The chair lift wasn’t working and we observed someone walking down the stairs backwards. This is a potential falls risk.

On the top floor the sluice room is key coded and we were told it’s not in use. We saw insect repellent, evidence that staff are decanting disinfectant. An umbrella, wrapping paper and a fire extinguisher dated 3/10.

In one lounge we saw a chair pushed up in front of the television. This television is the one we reported on in our last report which did not work properly. There were no blinds but the closures and string pullies were left in place.

In another lounge we saw a plug with a notice which read “do not switch off or unplug”. One socket by the television was taped. The flooring was uneven which may be a potential trip hazard. The call bell system is situated behind the Christmas tree so it was not easy to access and there was a folded curtain on a foot stool. This lounge was partitioned; there was a sliding door between the lounges which was broken and did not close properly. This room was not in use and we saw pictures, a hoist, there were two lamps in the corner behind the door and we could not find a light switch.

In the corridor one of the light bulbs was not working.

The fire extinguisher by the front door was not fixed securely to the wall. The evidence indicates that investment is required to improve the service. The impact for people using the service is facilities are of poor quality. They may not be able to sleep because some beds are not suitable and bed linen is of poor quality. People are at potential risk of falls due to inadequate lighting and flooring. People may feel that their belongings are not respected and people may feel they are not valued.


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The service is not compliant with The Care Homes (Wales) Regulations 2002, 16 (e), 16 (f), 16 (g), 16 (j) and 16 (k). This is because there staff do not implement and adhere to infection control practices/measures and some facilities and equipment are of poor quality. There is an offensive odour of urine throughout most parts of the home. The evidence includes:

Nine members of staff have undertaken infection control training between January and August 2013 which includes the deputy manager, one senior carer, four care staff one of whom is level 2, a cook and two office staff.

Following the inspection visit the responsible individual informed us that all staff members have completed a 63 page infection control booklet supplied by the National Health Service Harrogate and District Nursing Centre.

Upon entering the premises at 7.30am before any cooking was being undertaken we noted an odour of gas, we saw a sign in the kitchen above the sink which read “warning no gas appliance to be operated without the ventilation extraction system on”.

In the dining room we saw the radiator was leaking and a bowl from the kitchen had been placed underneath to catch the hot water. This radiator was not guarded. There was a sideboard, the doors didn’t close properly and were wedged closed with folded paper towels.

There was no personal protective clothing available such as gloves and aprons in any of the communal bathrooms and toilets or people’s bedrooms where personal care may be delivered. There is a supply kept in the medication room, but there is a key coded lock on this door which may make it difficult for staff to access protective clothing with ease.

In the communal toilets there were no blinds, liquid soap or paper towels available.

Someone was sat in a chair as they stood up and walked away we noticed the chair was stained. We examined the chair which was soaking wet and smelt of urine. Later in the morning we noticed that another person was sat in this chair in the same condition.

In the kitchen there was no waste receptacle to discard hand paper towels and waste.

There was a kitchen drawer missing.

The deep fryer did not look clean.

Protective aprons which people may use during their meal were folded and stored in a cupboard ready for use but these were unclean.

The area leading to the outside food store contained inappropriate storage. We saw a bed, chair, Zimmer frames, disused supermarket trolley and boxes; garden waste had also collected in this area.

In the laundry room there was no light. The washing machine was broken and out of order. Wet urine stained clothing and other unclean clothing was piled on top of newspaper on the floor. There was no labelling system in place to identify individual’s clothing. Red bags are not being used to wash soiled laundry. One member of staff came in to get a pair of trousers for someone, but these were creased and unlabelled. We asked how she knew they were the person’s trousers. She told us that she didn’t and that she would show other staff the trousers to establish if they were the right ones. We saw tea towels mixed in with people’s clothing.

In the downstairs communal bathroom the toilet was leaking and a baking dish from the kitchen was being used to catch the water. The backrest on the toilet was unclean.


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We saw mugs which were stained brown.

We discussed infection control measures with the responsible individual who confirmed there is no infection control champion at present who could undertake this responsibility to ensure best practices.

The freezer was not working properly it was making a noise; we could not open the compartment drawers because they were iced closed.

The refrigerator was switched on but when we opened the door there was a strong odour emanating from it and there was no food stock.

Following the inspection visit, visiting professionals informed us that they saw three beds which had been made up by staff but under the clean incontinent sheet the linen was soaked with urine this had seeped through to the duvet cover. We were told that a mat was placed underneath a commode in someone’s room which was unclean and when moved, it revealed smeared faeces. Staff had not cleaned this appropriately.

The evidence indicates that staff contravene infection control measures in accordance with good practice. The impact for people using the service is they may look dishevelled; their clothes will not always be clean or nicely pressed. People may wear clothes which are not theirs because there is no labelling system to identify which garments belong to whom and some staff do not know who clothes belong to. Staff adopts communal care practices when assisting people with personal care as a consequence people are at risk of infection due to toiletries being used between various people rather than used for individual use. As a consequence people’s dignity may not be maintained.

Version 1.1 07/2012

3

How we inspect and report on services We conduct two types of inspection;

baseline and focussed. Both consider the experience of people using services.

Baseline inspections assess whether the registration of a service is justified and

whether the conditions of registration are appropriate. For most services, we carry out these inspections every three years. Exceptions are registered child minders, out of school care, sessional care, crèches and open access provision, which are every four years.

At these inspections we check whether the service has a clear, effective Statement of Purpose and whether the service delivers on the commitments set out in its Statement of Purpose. In assessing whether registration is justified inspectors check that the service can demonstrate a history of compliance with regulations.

Focussed inspections consider the experience of people using services and we will look at compliance with regulations when poor outcomes for people using services are identified. We carry out these inspections in between baseline inspections. Focussed inspections will always consider the quality of life of people using services and may look at other areas.

Baseline and focussed inspections may be scheduled or carried out in response to concerns. Inspectors use a variety of methods to gather information during inspections. These may include;

Talking with people who use services and their representatives

Talking to staff and the manager

Looking at documentation

Observation of staff interactions with people and of the environment

Comments made within questionnaires returned from people who use services, staff and health and social care professionals

We inspect and report our findings under ‘Quality Themes’. Those relevant to each type of service are referred to within our inspection reports. Further information about what we do can be found in our leaflet ‘Improving Care and Social Services in Wales’. You can download this from our website, Improving Care and Social Services in Wales or ask us to send you a copy by telephoning your local CSSIW regional office.

http://wales.gov.uk/cssiwsubsite/newcssiw/publications/leaflets/puttingpeople/?lang=en

http://wales.gov.uk/cssiwsubsite/newcssiw/publications/leaflets/puttingpeople/?lang=en

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