Inspection on 28/09/09 for Madeley Manor Care Home

This is the latest available inspection report for this service, carried out on 28th September 2009.

CQC found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Madeley Manor Care Home 26/07/06

Madeley Manor Care Home 31/10/05

Madeley Manor Care Home 06/04/05

Madeley Manor Care Home 28/09/04

Madeley Manor Care Home 28/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report Care homes for older people Name: Address: Madeley Manor Care Home Heighley Castle Way Madeley Crewe Cheshire CW3 9HJ     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Linda Clowes     Date: 2 8 0 9 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Madeley Manor Care Home Heighley Castle Way Madeley Crewe Cheshire CW3 9HJ 01782750610 01782751545 diane.maddock@xln.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Madeley Manor Care Home Limited care home 42 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 42 The registered person may provide the following category of service only: Care Home with Nursing (Code N); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 5; Mental disorder, excluding learning disability or dementia over 65 years of age (MD(E)) 5; Old age, not falling within any other category (OP) 42; Physical disability (PD) 42 Date of last inspection 5 0 0 42 Over 65 0 5 42 0 Care Homes for Older People Page 4 of 28 Brief description of the care home Madeley Manor Care Home is registered to provide residential and nursing care for up to 42 elderly persons over the age of 65 years, five of whom may have a mental disability, five of whom may have dementia and forty-two of whom may have a physical disability. There are three double/shared bedrooms. The service is using some shared rooms for single occupancy and will currently admit a total of only thirty-nine people The Home is a Grade II listed country house situated in landscaped gardens on the outskirts of Madeley in a well established residential area. The Home is in close proximity to Madeley village, six miles from Newcastle-under-Lyme and eight miles from junction 15 of the M6 motorway. The Home is not well served by local transport but is easily accessible by car and has ample parking space to the front of the home. Accommodation is provided on three floors that are accessed by a vertical shaft passenger lift or a main staircase. All areas within the Home are accessible for wheelchairs. A high proportion of rooms have en-suite facilities. Madeley Manor has two well appointed sitting rooms overlooking the extensive grounds and a good sized dining room. There is access to the grounds and patio area. The Home provides a range of activities for people who use the service and has access to a community minibus to provide day trips. The General Manager confirmed that there is a range of fees for the service dependant on the type of service provided to meet the individual needs of people who use the service and it is recommended that interested parties should contact the home directly to confirm fees. Additional charges were made for newspapers, magazines, telephones, toiletries and hairdressing services. The latest website address is: www.madeleymanor.co.uk Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last Key Inspection for this service took place on 1 November 2007 and the home was given a quality rating of two stars (good). We carried out an Annual Service Review on 18 September 2008 which identified from the information we received that the quality of the service had been maintained. It is our policy to carry out a Key Inspection visit every two years for a service with a quality rating of good. This was an unannounced Key Inspection. We inspected against the National Minimum Standards for Care Homes for Older People and the Care Homes Regulations 2001. The objective of the inspection is to evaluate whether people who use the service and their family carers experience services of good quality that offer and promote independence. The Responsible Individual, Diane Maddock, and Registered Manager, Karen Thurston, were present during this inspection which took place over a period of approximately 7.5 hours. We looked at peoples assessments, care plans, personnel files, complaints Care Homes for Older People Page 6 of 28 files, medication records, health and safety records and gave feedback throughout. We case tracked four of the people using the service. This is a focussed methodology that we use to analyse the care offered in the home. This means that we checked all aspects of their care and the records kept for them. We spoke to people using the service, their relatives, staff and analysed surveys received prior to the inspection. Prior to the inspection visit the providers had completed a self-assessment tool which is known as the Annual Quality Assurance Assessment (AQAA). Completion of the AQAA is a legal requirement and it enables the service to undertake a self-assessment which focuses on how well outcomes are met for people using the service. Information from this AQAA was used to plan the inspection visit and references to it have been made in this report. The AQAA was returned promtly and gave us a reasonable picture of the current situation within the service. This document could be improved by providing examples and information regarding some of the statements made. A high number of people who use the service were very frail, have dementia or confusion and are not able to give us a full response to some aspects of their care but the vast majority are able to tell us that staff are kind to them and help them. We spoke with several relatives on the day who are frequent visitors to the home and who were able to tell us that they are satisfied with the services provided at Madeley Manor. They tell us they are made welcome and have observed over many months good interaction between the staff team and people who use the service. People who responded to surveys tell us they are satisfied with the service stating The staff are very good. I am well looked after. Managers and staff listen to what we say and respond promptly. I have no concerns regarding the care provided to my relative. As a consequence of this visit we have concluded that Madeley Manor continues to provide a good service. We have made three recommendations to improve medication practices. We have been advised that the website address for the service has changed. At the time of issuing the final report we are unable to change the report template to reflect this. We list it below however: www.madeleymanor.co.uk Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 8 of 28 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the information they need to make an informed choice about where to live. No one is admitted to the home without having had their needs assessed and being assured that these will be met. Evidence: No requirements were made in this outcome area in the last Key Inspection report. The care home is registered for forty-two older people. However, the service has decided to utilize some of the previously designated shared rooms for single occupancy and currently admits only thirty-nine. All but seven of the current people who use the service are wheelchair dependent and benefit from extra space in their bedrooms. The home provides an information pack for people who are interested in admission to Madeley Manor which includes a copy of the Statement of Purpose, Service User Care Homes for Older People Page 10 of 28 Evidence: Guide, Complaints Procedure and various explanatory leaflets. People we spoke with and those who returned surveys told us that they had sufficient information about the home prior to admission to make an informed choice as to whether they wished to live there or not. Several people had tested the water by having short-stay/respite visits or, alternatively, they and/or their representatives had visited to see the home prior to admission. The home encourages people to visit and look at what they have to offer. There are varying charges for accommodation dependent on whether people are publicly or privately funded and the level of care provided. People should contact the service directly to find out what the current fees are. We identified that people who are privately funded are issued with clear and unambiguous contracts outlining Terms of Residency and payment arrangements. Admissions only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the person. The Registered Manager carries out a pre-admission assessment before agreeing to admission. The service has recently been awarded a contract with the Primary Care Trust to provide continuing care. The home does not provide intermediate care. Therefore, Standard 6 has not been assessed. Care Homes for Older People Page 11 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal and healthcare support using a person centred approach. People who use the service are treated with respect and their right to privacy is upheld. Evidence: No requirements were made in this outcome area in the last Key Inspection Report. A recommendation was made that the service should evidence that people who use the service and their advocates have input into care plans. As part of this inspection we monitored (case tracked) the files of four people who use the service three of whom were receiving nursing care and one residential care. Everyone has a comprehensive care plan that covers their health and social care needs and which is reviewed monthly or at point of change. The plans of care and associated risk assessments for the people case tracked are comprehensive and current, giving staff instruction on all aspects of care delivery. There was documentary evidence to confirm that people and their representatives are being included in the Care Homes for Older People Page 12 of 28 Evidence: compilation of care plans and also at times of review. We consider, therefore, that the recommendation in the last report has been met. People have access to healthcare and remedial services. There is a record of discussions with and interventions by health care professionals when staff are concerned about the person. We monitored medication procedures during this visit. The medication for the people we case tracked is, in the main, in blister packs/monitored dose system that have been filled by a pharmacist. The Medication Administration Records (MAR) showed the numbers of each tablet held in the home. Tablets in blister packs/monitored dose systems are stored securely prior to being placed in the medication trolley and are administered by a nurse. The MAR charts are complete and show an audit trail. Numbers of tablets corresponded with the MAR and it was possible to identify where medicines had not been administered, e.g. where these have been refused or otherwise. We identified that prescribed creams were being signed as administered by nurses where, in practice, they were being administered by care assistants whilst they were carrying out personal care tasks. All prescribed medication/treatments should be signed by the person who administers and we have, therefore, made a recommendation regarding this as part of this report. The service should ensure that appropriate training is provided to all staff who administer prescribed medication/treatments. We have also recommended that written protocols are provided for all as required medication in order to ensure that such medication/treatment is administered by the team with consistancy and transparency. This will ensure that there is a unified team approach to such decision making. People we spoke with, without exception, tell us that they are treated with respect and that their privacy and dignity are upheld. Everyone who returned surveys told us that staff listen to what they say and are always available when they need them. Many comments were added to surveys as outlined below: My mum lives happily at Madeley Manor and receives the best possible care. The care home keeps us informed every step of the way with my mothers healthcare Care Homes for Older People Page 13 of 28 Evidence: which I find extremely helpful. I visit most days and feel the attention and understanding to mothers needs is very good by all the staff at Madeley Manor. Every aspect of care is to a high standard. There is not any one thing that is better. The home provides good personal and medical care. Friendly staff. I think it maintains very good standards and the staff are always friendly. Care is excellent. The staff are excellent. If anything had arisen at the home that needed addressing the staff have always been 100 approachable. Knowing (name) is in a caring and well-run establishment gives me peace of mind. Priceless. The home is a safe place for the residents and for relatives in the knowledge of the care and attention received there. They look after me very well. Care Homes for Older People Page 14 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are helped to exercise control over their lives and enjoy the lifestyle of their choice. Evidence: No requirements were made in this outcome area in the last Key Inspection report. The service is committed to enabling people to develop or maintain skills and providing stimulation. We spoke with several people who live in the home on the day of our visit as not all of the people being case tracked were able to express their views to us. Everyone agreed that they are well supported by staff in the home. The home has two activity co-ordinators that are in the home most days. A Daily Activities Programme was displayed in the main hallway. We observed people undertaking activities on the day. A minibus is used to take small numbers of people on local trips. We noticed that the co-ordinators are booked to attend a formal Activities for Clients training event in October. Care Homes for Older People Page 15 of 28 Evidence: Surveys tell us that the home always or usually arranges activities people can take part in if they want. A few have added comments: I enjoy day trips out but wish they were more frequent. With extra staff they could take people out to shops or for little trips out. I would like more musical entertainment. Everyone tells us on the day that they enjoy the meals served in the home and said they had a choice if they did not like something. One person told us in their survey Food portion size is variable, sometimes too small. We monitored the lunch and teatime meals in the attractive dining room. People were having a variety of meals at lunch (three courses) including a hot meal or salad. For tea there was something on toast, soup or sandwiches. Everyone spoken to confirmed they enjoyed the food served and that there was always sufficient quantity and was of good quality. Staff were observed assisting or prompting people in a kindly and sensitive way. We visited the kitchen and spoke with the cook. There is a four-week rotational menu which also takes account of peoples preferences. Residents Meetings take place and the records show that food is often discussed. Each person has an activities monitoring form in order to monitor interaction, integration and levels of dependency. Activities Co-ordinators target activities on the ability of people who use the service. Small numbers of people are taken out in the minibus and staff have to be organised to accommodate this. There had been a recent Summer Fayre which had raised money for the Residents Comforts Fund. Photographs of the event were displayed in an album so that people could look at this and show their visitors. Peoples individual routines are catered for. Some people like to lie in each morning others are late risers - individual preferences are accommodated. We observed throughout the day that people who use the service were calm and relaxed and confident in their approaches to managers and staff. The service has a monthly Newsletter to keep people up to date with events in the home. During recent weeks there had been trips to Bridgemere and Trentham Gardens. A Guitarist/singer visits regularly; a clothes party is planned for next week. Care Homes for Older People Page 16 of 28 Evidence: The home won silver in this years Britain in Bloom competition and is aiming for gold next year. Care Homes for Older People Page 17 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service and their relatives are confident that their complaints are listened to and handled appropriately. The service has policies and procedures in place to ensure that people are protected from abuse. Evidence: No requirements were made in this outcome area in the last Key Inspection Report. The home has an open culture that allows people to express their views and concerns in a safe and understanding way. We noticed that people who use the service are confident and relaxed in their approaches to staff. The service has a complaints procedure that is supplied to everyone living in the home and is also displayed in the main hallway. The AQAA tells us that there have been no complaints received in the home in the last twelve months. We, the commission, have received no complaints about this service. We looked at the complaints and comments file and found a record of seventeen comments recorded the majority were complimentary and expressing gratitute and thanks for good service. Three of the comments were made by people who wished to improve their service and the record showed that these had been addressed without delay. There are policies and procedures for safeguarding adults. A recommendation was Care Homes for Older People Page 18 of 28 Evidence: made in the last Key Inspection report for updated Safeguarding Training to be given. Staff training records show that they have attended Protection of Vulnerable Adults/Safeguarding training provided by an external trainer. We consider, therefore, that this recommendation has been met. Staff are informed about whistle blowing procedures should they have concerns about poor practice within the service. The AQAA tells us that there have been no safeguarding referrals or investigations in the last twelve months. We, the commission, have received no safeguarding alerts about the service in the past twelve months. Safeguarding training is also proposed for ancilliary staff - maintenance, kitchen and domestics. Everyone who returned surveys tells us that they know how to make a complaint. Care Homes for Older People Page 19 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, well-maintained environment that is clean, pleasant and hygienic. Evidence: No requirements were made in this outcome area in the last Key Inspection report. The home is suitable for purpose and provides people with a comfortable, homely and pleasant environment in which to live. A smoke room is available. Bedrooms are warm, pleasantly decorated and comfortable. Many have en-suite facilities. People have furnished them with small items from home to make them more personal. Bathrooms and toilets are situated conveniently throughout the home. People are able to sit in communal areas with visitors or in their own rooms. There are also seating areas located in the corridors that are a favourite spot with some people who like to sit and watch people passing by. The Laundry is located in the basement away from the main areas of the home. There is a laundry shute so that staff can send soiled linen to the laundry without them having to visit. This cuts down risk of cross-contamination. The AQAA tells us that twenty-six people have attended training in prevention and control of infection. Care Homes for Older People Page 20 of 28 Evidence: We inspected all areas of the home and there were no offensive odours. People who returned surveys tell us that the home is always clean and fresh. Madeley Manor would be much improved if the driveway is resurfaced. The Caution. Uneven Surface signs displayed down the drive are needed as there are many potholes. The AQAA acknowledges that the driveway needs improvement. One person has said in their survey I think the drive could be improved on. We spoke with people who use wheelchairs who tell us that the driveway makes it difficult for them to venture outside without assistance. It is a pity that this feature is detracting from a very attractive building and location and may also be affecting peoples independence as they feel unable to go outside the building unaided. Care Homes for Older People Page 21 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient experienced and qualified staff deployed to meet the needs of people who use the service. Evidence: No requirements were made in this outcome area in the last inspection report. Staffing was not raised as an issue with anyone we spoke with on the day or in responses to surveys. The AQAA tells us that none of the shifts in the past three months have had to be covered by agency staff. This promotes consistency for people who use the service and it is apparent that people have confidence in the staff team who care for them. We looked at three staff files and found robust recruitment procedures that include the taking up of references and criminal record bureau enhanced disclosures (police checks). This ensures that people using the service are supported by staff suitable to care for vulnerable people. We looked at the training records of the staff we were case tracking. Staff had attained all mandatory training for their roles. Staff supervision is carried out regularly and there are also regular staff meetings. We have made a recommendation that all staff responsible for the administration of medication/treatments receive appropriate Care Homes for Older People Page 22 of 28 Evidence: training to enable them to do so safely and competently. Staff who responded to surveys tell us that they are given training that helps them to understand and meet the individual needs of people; keeps them up to date with new ways of working and gives them enough knowledge about health care provision. All staff who responded to surveys confirmed that they were well supported by management. They added the following comments: I love to work here. The management are lovely, always there to listen to you when or if you have a problem. I enjoy being part of the working team at Madeley Manor. The home promotes good quality of life to all the service users. The home caters for individual needs of residents, makes sure staff are well trained. Makes sure the home is a safe place for everyone. They deliver excellent care. There is good staff training. Management have an open door policy and are always there to listen and help in any way they can. The home supports all it staff. Activities are done each day. I can not think of anything they could do any better. We have regular opportunities for training. Care Homes for Older People Page 23 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered manager is qualified and experienced to run the home. The home is run in the best interests of people who use the service. Evidence: No requirements were made in this outcome area in the last Key Inspection report. The registered manager has the required qualifications and experience and is competent to run the home. She is supported by the General Manager and Responsible Individual. Both have a clear understanding of the key principles and focus of the service and work continuously to improve the service. There is a strong focus on equality and diversity issues and an ethos of being open and transparent in all areas of practice and running the home. The AQAA contains clear and relevant information which was supported by a wide range of evidence during the inspection. It was returned to us within the specified timescale. Care Homes for Older People Page 24 of 28 Evidence: There are sound policies and procedures in place to support all areas of the service and the manager ensures that the staff team translate these into practice. There are checks and balances in place for all systems to ensure that everyone is carrying out their role in a competent and effective manner. Supervision and team meetings keep the team focussed on outcomes for people who use the service and ensure that the team is complying with the homes policies and procedures. All records requested were promptly produced. Fire Records, Fire Training and Maintenance Records are neat, tidy and up to date. The home encourages families to look after peoples finances where possible. Each person for whom they look after small sums of money has a financial record. We checked the financial records for four people. We checked monies held on their behalf and scrutinised the records. All were accurate and explicit. The service had carried out a recent Service Satisfaction Survey (Quality Audit). There was positive feedback. The surveys could be improved by adding a date in order to verify when they were issued/returned. The Certificate of Registration is displayed in the home as required by our regulations. There is current insurance in place. Care Homes for Older People Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 9 It is recommended that the service ensures that all medicines/treatments are administered as prescribed and that there is an accurate record to confirm this. The person who administers prescribed treatments should be the person who completes a record to confirm this. Risk assessments and written protocols should be in place to cover all areas of medication practice including as required medication. This will ensure that decisions about the administration of as required medication are consistent , transparent and unambiguous. This will assure people who use the service that they are in safe hands. All staff who are responsible for the administration of prescribed medication/treatments should receive robust training to enable them to appropriately administer the prescribed treatments the service asks them to carry out. 2 9 3 30 Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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