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Inspection on 11/05/09 for Seabrooke Manor Nursing Home

Also see our care home review for Seabrooke Manor Nursing Home for more information

This is the latest available inspection report for this service, carried out on 11th May 2009.

CQC found this care home to be providing an Excellent 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home continues to be run by a registered manager who is highly competent and very experienced, and who makes the care of the residents a priority. He works with a strong, consistent staff team who are all committed to improving the current high standards of care delivered at the home. The nutritional needs of all residents are well considered so that mealtimes are a protected time which enables residents and staff to concentrate on ensuring that these times are enjoyable and beneficial for the health and welfare of the residents. The administration of medication is very good. The storage and management of controlled drugs is also very good, and there is a robust audit system in place for all medication. Training for all staff is a priority within the service and recent training has included the newly introduced Mental Capacity Act 2005 and the Deprivation of Liberty. The handling of complaints and safeguarding is also robust, with outcomes being used to improve service delivery. The environment is clean and well maintained and free from offensive odours. There is an effective programme of refurbishment and redecoration in place. The kitchen area has recently achieved a 5 star rating awarded by the local environmental health officers.

What has improved since the last inspection?

The environment on Saxon House has improved with the painting of murals on the corridor walls. This has been done by students from a local college, and one corridor has scenes of Valentine Park, and the other corridor has various shop fronts. Also some of the bedroom doors have been refurbished so that they represent a front door. The two requirements made at the last key inspection around medication have been complied with. The quality and compliance monitoring systems within the home have improved, and there is increased availability of Quality and Compliance expertise within the wider organisation to access if required.

What the care home could do better:

Although end of life care plans are in place for many of the residents, there is still a gap for those residents accommodated on Saxon House. We are confident that residents on this house can be sure that at the time of their death, staff would treat them and their family with care, sensitivity and respect, but care plans must contain adequate and appropriate information on end of life, and staff on this unit must begin to grapple with this important area of care planning. Protocols for the administration of PRN (as required) medication are included in the individual care plans, where necessary, but we would recommend that this information is also included with the medication administration records (MAR), since it will provide more easily accessible information when staff are actually administering medication.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Seabrooke Manor Nursing Home Lavender Place Ilford Essex IG1 2BJ     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sandra Parnell-Hopkinson     Date: 1 1 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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: Seabrooke Manor Nursing Home Lavender Place Ilford Essex IG1 2BJ 02085535538 02085142283 maherb@bupa.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : BUPA Care Homes (CFHCare) Ltd care home 120 Number of places (if applicable): Under 65 Over 65 0 0 120 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: 120 120 0 The maximum number of service users who can be accommodated is: 120 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: Old age, not falling within any other category - Code OP Dementia - Code DE Mental Disorder, excluding learning disability or dementia - Code MD Date of last inspection Brief description of the care home Seabrooke Manor is a 120-bed home owned and operated by BUPA Care Homes Ltd. The home is purpose built and is divided into four separately staffed units. These provide care for specific client groups: people over sixty-five years requiring nursing care and personal care due to frailty/ illness and people with dementia, some of whom require assistance with personal care. The home is situated in a residential area of Ilford in the London Borough of Redbridge; approximately 10-15 minutes walk from Care Homes for Older People Page 4 of 28 Brief description of the care home the main road and public transport. The external grounds and building are well maintained and secure. Fees can be obtained on request and are dependent upon the assessment as to the level of need. A copy of the Statement of Purpose and Service User Guide to the home is made available to both the resident and the family. There is a copy of the guide in each bedroom, and copies of both these documents are available at the main reception and on each unit. Copies of the most recent inspection report are located on each unit and on request from administrative staff. 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: three star excellent 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: This inspection was unannounced and started at 08:00 hours and was completed at 16:00 hours. All of the 4 houses were visited and case tracking took place on each of the houses. During the day we spoke to the registered manager, nursing, care and ancillary staff. We were also able to speak to many of the residents on each of the houses, and also to some visitors. We telephoned health and social care professionals to obtain their views on the service. Information was also taken from the returned completed AQAA (annual quality assurance assessment), notifications and other information which had been received by the Commission. Care Homes for Older People Page 6 of 28 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 set out on page 4. Care Homes for Older People Page 8 of 28 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 9 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 10 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may use this service, and their representatives, are given the information needed to help them to choose a home that will meet their needs. Evidence: We found that significant time and effort is spent planning to make the admission to the home personal and well managed. Prospective residents and their families are treated as individuals and with dignity and respect for the life-changing decisions they need to make. There is a high value on responding to individual needs for information, reassurance and support. This was confirmed in discussions with several relatives, one of whom told us the information was really good and when we visited, before making a decision, the staff were really helpful, understanding and informative. The service also uses mystery shoppers to ensure that the home is providing the correct information to enquirers. Staff involved in dealing with enquiries undertake training in this important area. Care Homes for Older People Page 11 of 28 Evidence: Information can also be provided in different languages and formats where necessary. All new residents receive a comprehensive needs assessment before admission and this is carried out by staff who have the skills and sensitivity. The service is highly efficient in obtaining a summary of any assessment undertaken through care management arrangements, and insist on receiving a copy of the care plan before admission. For those individuals who are self-funding, the assessment is undertaken by a highly qualified member of staff. Prospective residents and their families are involved in the assessment process, and information is gathered from a range of sources. The assessment focuses on achieving positive outcomes for people, and this is now helped by the new Quest assessment and personal care planning programme used by BUPA care homes. Before agreeing admission the service carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet his/her needs. Wherever possible prospective residents are given the opportunity to spend time in the home and staff make every effort to make them feel comfortable and enables them to ask any questions. The service also ensures that the ethnic and diversity needs of the individual person are taken into account during the assessment and care planning stages. All residents receive a contract or statement of terms and conditions. Clear information is given about fees and extra charges. The service encourages the use of advocates to help those people who require this service. Care Homes for Older People Page 12 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice throughout the service. Evidence: We found that residents receive effective personal and healthcare support using a person centred approach with support provided based upon the rights of dignity, equality, fairness, autonomy and respect. Staff are very aware that the way in which support is given is a key issue for people, and individual plans clearly record a persons personal and healthcare needs and detail how they will be delivered. The care plans are very comprehensive and staff use these as a working tool. Care plans are reviewed monthly or more frequently if the need is indicated. During the inspection process we observed that the practices within the home reflected residents needs around equality and diversity. We observed that care was person led, and that personal support was flexible. Residents spoken to confirmed this, and one lady told us I can get up when I want to Care Homes for Older People Page 13 of 28 Evidence: and go to bed when I want to. Staff are always pleasant and there to give me the help I want when I need it. In discussions with some of the staff they demonstrated expert knowledge about individual personal needs when providing support and care. This was true on all of the houses, but was particularly evident on both Roman and Saxon where people living with dementia are cared for. People living with dementia are less able to express their wishes which is why staff need to have expert knowledge of the individual, and this was well demonstrated during the inspection process. We also observed that staff were very alert to changes in mood, behaviour and wellbeing and responded appropriately and took any necessary action. Files indicated that residents have access to health and social care professionals including a social worker, GP, optician, dentist, chiropodist, dietician, specialist consultant or tissue viability nurse. Regular appointments are seen as important and there are systems in place to ensure that residents do not miss these important visits. Aids and equipment are provided to encourage maximum independence, and all equipment and aids are regularly maintained and replaced where necessary. One resident was immobile when admitted to the home, is now walking with the aid of a zimmer frame, and is also helping with laying tables. Risk assessments are routinely undertaken for all residents around nutrition, manual handling, continence, pressure sore prevention, falls and, where necessary, behaviours that challenge. All fluid monitoring, and turning charts were up to date. The home has developed efficient medication policy, procedure and practice guidance and staff have access to this written information and when spoken to understood their role and responsibilities. Staff work with individuals regarding any refusal to take medication, and will discuss with the persons GP alternative forms of medication which may be more appropriate for the individual. Medication administration records were inspected and found to be in good order, as were the controlled drugs registers. The home has implemented a robust medication audit system which has improved medication and recording within the service. Protocols for the use of PRN (as required) medication are in place within the individual care plans, but we would recommend that this information is also contained within the medication administration records (MARs) and this was discussed with the manager and the house managers during the inspection. The service is highly efficient when caring for residents who are terminally ill or dying. End of life wishes are discussed with residents and their families in a sensitive way, and during the development of the person centred care plan. The documentation of end of life still needs to be addressed by Saxon House, and this was discussed with both the House Manager and the General Manager during the inspection. In house and external training is available for all staff, together with practical advice and continuous support and opportunities to discuss any areas of anxiety and concern. Staff work to a very high standard and the home works closely with external professionals and specialists for advice and support to help the residents and their families. On the Care Homes for Older People Page 14 of 28 Evidence: afternoon of the inspection some staff were attending training on the use of syringe drivers. Care Homes for Older People Page 15 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The lifestyle within the home matches the expectations and preferences of the residents. The ethos and practice of the service and of the staff teams promote opportunities for residents to remain independent, exercise choice and express their wishes. The nutritional needs of residents are well considered and mealtimes are seen as being an important time for all residents. Evidence: The service understands and actively promotes the importance of respecting the human rights of people living at Seabrooke Manor, and equality, dignity, respect and independence are all seen as central to the care and support being provided. We observed residents being given opportunities to participate in a range of activities, and this was also supported from viewing care plans and also programmes of planned activities/entertainment. The views of residents are sought and taken on board in the planning of the daily routines within the home, and in arranging activities both in the home and the community. Routines were generally person centred and responsive to the changing needs, choices and wishes of the individual. One resident told us I now go to a day centre twice a week and really enjoy meeting other people of my own faith and culture. I have joined the pottery class which is great. On the day of the Care Homes for Older People Page 16 of 28 Evidence: inspection some residents from all of the houses were watching a film in the cinema situated on Saxon House, and they all seemed to be enjoying it. The home is accredited with the Cinnamon Trust and will accept pets into the home. Signage and decor on both Roman and Saxon Houses is conducive to those people living with dementia. A great deal of work has been undertaken on Saxon House where the corridors have been painted with murals by students from a local college. One corridor has scenes of Valentines Park and the other corridor has scenes of various shop fronts. Some of the bedroom doors on this House have been refurbished so that they now look like front doors along a street. Memory boxes are in place outside of the bedrooms. The need for residents to maintain family and personal relationships is seen as very important, and visits by family and friends are encouraged. We spoke to a family who were visiting and they told us we are really pleased that we chose this home, the staff are wonderful and extremely patient and nothing ever seems to be too much trouble. We are always given tea and biscuits when we come. The service actively supports people to be as independent as is possible, and one resident who was immobile on admission is now walking with a zimmer frame and helps to lay and clear dining tables. Meals are very well balanced and highly nutritional and cater for varying cultural and dietary needs of the residents. Mealtimes are also a protected time to enable residents to concentrate on eating and drinking without other distractions. This is especially important for those residents living with dementia. Drinks and snack are also freely available throughout the day and night. For those individuals who need support during mealtimes, staff were on hand to give assistance. Such assistance was seen to be given in a discrete and sensitive way. Mealtimes appeared to be relaxed and staff were patient and helpful and allowed individuals the time they needed to finish their meal. One care plan seen indicated that the individual liked to walk about when eating, and therefore we observed that finger foods were being provided. Fresh fruit is available to all residents on a daily basis, and this was confirmed by our own observations and in discussions with residents and visitors. 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 excellent 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 are able to express their concerns, and have access to a robust, effective complaints procedure, and are protected from abuse and have their rights protected. Evidence: We looked at the complaints file and this and the AQAA (annual quality assurance assessment) confirmed that the service had received 11 complaints within the last 12 months. The majority of the complaints were resolved in accordance with the timescales as laid down in the current complaints procedure. 7 of the complaints were upheld and the outcomes were used to ensure that any processes were changed and improvements made to the service where necessary. We spoke to visitors who told us that they were aware of the complaints procedure, and knew who to complain to if necessary. During discussions with some staff they demonstrated an understanding of the need to take all complaints seriously, and deal with them in an effective manner for the benefit of residents and the service. The home has an open culture where individuals feel safe and supported to share any concerns in relation to their protection and safety. One resident told us I would always speak to the nurse in charge if I had any concerns, she is very kind and always listens and takes on board what I am saying. Safeguarding issues at the home are always taken seriously and the manager is very Care Homes for Older People Page 18 of 28 Evidence: clear as to when an incident needs to be referred to the local authority as part of the local safeguarding procedures. The manager is always open and transparent when discussing incidents with external agencies. All staff working within the home are trained in safeguarding adults, and when talking to some staff they demonstrated a good knowledge and understanding in this area. Staff were also able to demonstrate what restraint was, and that they would always look for alternatives to its use. Equipment such as bed rails, recliner chairs and wheelchair belts are only used when absolutely necessary and within a risk assessment framework with the individual resident, and/or family, being fully involved in decisions. There had not been any referrals made under the Mental Capacity Act 2005, Deprivation of Liberty. The manager and many of the staff had undertaken training in this important area, and further training courses had been organised for the future. 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. The environment in all of the houses is of a good standard and provides residents with a clean, safe and comfortable place in which to live. Evidence: We visited the 4 houses and found them all to be free from offensive odours, clean and maintained to a good standard. There is an ongoing programme of refurbishment and redecoration throughout the service. A local college had been involved in painting colourful murals on the walls of the corridors in Saxon House, and some of the bedroom doors have been refurbished to look like front doors. Bedrooms on all 4 houses have been personalised to the individual needs of the residents, and those seen were well furnished and decorated. The call alarm systems were accessible to residents, but where residents are unable to use this system the use of other forms of assistive technology are being used. Necessary equipment such as hoists are in place and are regularly maintained. Hand washing facilities are prominently sited and staff were observed to be practising adequate standards of hand hygiene. The external garden areas were well maintained and garden furniture was in situ for the use of the residents. We did not visit the kitchen and laundry areas as these had always been found to be of a high standard on previous visits, and a recent visit had been undertaken by the local Care Homes for Older People Page 20 of 28 Evidence: environmental health officers who had awarded the kitchen a 5 star rating. Residents told us that their clothes were always well laundered and always had their own clothes returned to them. 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. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. Residents benefit from the minimal use of agency staff. Evidence: We looked at the staff rotas on all 4 houses and found that the staffing levels of qualified nurses and care staff were sufficient to meet the current nursing and personal care needs of the residents. There is also very little use of agency staff which is good for residents, since it provides a more consistent level of care for them. In all 4 of the houses were saw effective team working and staff told us that they all worked as a team because this was better for the residents and for themselves. We spoke to an ancillary member of staff who also told us that she felt part of the whole team on that house, and that she enjoyed chatting to the residents. Training within the service is good and the evidence of this was seen during the inspection process in the interaction/caring that staff had with residents. Training has included dementia care, syringe drivers, palliative care, manual handling, infection control, food hygiene, safeguarding, equality and diversity, Mental Capacity Act 2005 and also Deprivation of Liberty. The home is now accredited by the Liverpool Care Pathway and is also working towards the Gold Standard Framework accreditation. We did not look at the staff recruitment files at this inspection as on previous visits these had always been maintained to a high standard with all of the necessary checks Care Homes for Older People Page 22 of 28 Evidence: and references being taken up. This ongoing compliance was confirmed by the service in the AQAA (annual quality assurance assessment), and in the quality audits undertaken by the wider organisation. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by the organisation and implemented by a qualified and competent manager. Evidence: The registered manager has the required qualification and experience and is highly competent to run the home and ensures it meets the stated aims and objectives. The manager continues to demonstrate a sound knowledge of both strategic and financial planning, and demonstrates a sound knowledge of the organisations strategic and financial planning systems. The manager communicates a clear sense of direction and this was also confirmed in discussions with staff. He is able to demonstrate a sound understanding and application of best practice operational systems, particularly in relation to continuous improvement, customer satisfaction, and quality assurance. Equality and diversity, human rights and person centred care are given priority by the manager. The manner Care Homes for Older People Page 24 of 28 Evidence: in which the home is run shows an understanding of peoples needs in respect of equality and diversity. The organisation has a comprehensive set of policies and procedures and these are regularly reviewed by experts and updated when required. The manager was able to demonstrate a good understanding of the policies and procedures, and these are also made available to staff. Spot checks and quality monitoring systems provide management evidence that practices reflects the homes and the organisations policies and procedures. The home is supported by a national team of quality and compliance officers whose role includes supporting quality issues within the home, auditing and providing guidance on a range of issues including health and safety. Recently new systems and audits have been introduced for the management of residents finances. We were told by staff that the manager provides a good role model for them, and feedback from health and social care professionals is that the home provides high quality services. The AQAA (annual quality assurance assessment) contains very good information that was fully supported by appropriate evidence gathered during the inspection process, and this included the importance of equality and diversity and listening to residents and families. Generally record keeping is of a consistently high standard and records are kept securely, but residents can gain access to their records. The manager and his staff have a good understanding of risk assessment processes which is underpinned by promoting independence and choice. Under the continued leadership of the registered manager the service continues to improve, and the manager continues to work closely with the Commission and keeps us informed of all incidents which occur at the home. 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 We would recommend that the protocols for PRN (as required) medication are also included within the medication administration records (MARs). We would recommend that priority be given to the development of end of life care plans for residents on Saxon House. This will ultimately benefit both residents and staff through a greater knowledge and awareness of the desired outcomes for end of life. 2 11 Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 28 of 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!