Inspection on 02/12/08 for Beechfield

This inspection was carried out on 2nd December 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beechfield 20/02/07

Beechfield 08/12/05

Beechfield 03/05/05

Beechfield 23/12/04

Beechfield 13/10/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Beechfield 22 Hanger Hill Weybridge Surrey KT13 9XS     The quality rating for this care home is:   two star good 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: Joseph Croft     Date: 0 2 1 2 2 0 0 8 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. the things that people have said are important to them: They reflect 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 27 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.csci.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Beechfield 22 Hanger Hill Weybridge Surrey KT13 9XS 01932842380 01932820449 mailbeechfield@btconnect.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable): Beechfield Trust Limited The registered provider is responsible for running the service Name of registered manager (if applicable) Mrs Audrey Claire Sentinella Type of registration: Number of places registered: care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 16 The registered person may provide the following category of service only: Care home with nursing (N) to service users of the following gender: Either whose primary care needs on admission to the home are within the following category : Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Beechfield is a residential care home for active Christian Scientists. It opened in 1946 and was the first Christian Science care home in Britain. Residents rely on bible-based methods of spiritual healing rather than on conventional western medicine and care. The reliance of Christian Scientists on prayer alone for their health care is an integral Care Homes for Older People Page 4 of 27 Over 65 16 0 Brief description of the care home part of their worship of God and practice of their religion. No medical processes, remedies or interventions are used at Beechfield. The home is registered as a care home not providing medicines or medical treatment. It is registered for up to 16 people. The age range of the persons to be accommodated is older persons aged 65 years and over. The home is situated in Weybridge opposite the cricket green and close to the local shops. The railway station and several bus routes are also in close proximity. The home stands in its own well established and maintained grounds. There is a lift serving the upper floor. There are sixteen single rooms; all but one has an ensuite toilet. Two have showers and two have baths. The major part of the home is wheelchair accessible. The Beechfield Trust members are actively involved with the home; several of the staff and management are active Christian Scientists themselves. There are ample parking facilities at the front of the building. The weekly fees are 575 pounds. Care Homes for Older People Page 5 of 27 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 quality rating for this service is 2 Star. This means the people who use the service experience good quality outcomes. The last key inspection was on the 20th February 2007. The Commission For Social Care Inspection (CSCI) (us) (we) undertook an unannounced site visit on the 2nd December 2008 using the Inspecting for Better Lives (IBL) process. Regulation Inspector Mr Joe Croft undertook this visit and the registered manager assisted him throughout. This site visit took place over a period of seven hours, Care Homes for Older People Page 6 of 27 commencing at 9:00 and concluding at 16:30. Also assisting on this site visit was an Expert by Experience. This is a person who either has a shared experience of using services or understands how people in this service communicate. They visited the home with us to help us get a picture of what it is like to live in or use the service. The inspection process included a tour of the premises, observation of practice and the sampling of care plans and risk assessments. Other documents sampled included pre admission assessments, the menu, training records, staff recruitment files, some policies and procedures and health and safety records. The inspector had discussions with the manager, two members of staff, the afternoon cook and residents. The Expert by Experience had lunch with the residents and conversations in their bedrooms. Residents told us that they were happy living at the home, they like their bedrooms and were complimentary about the care they receive from staff. Residents are able to make choices within all aspects of their daily lives, when to get up, when to go to bed and what clothes they would like to wear. The Annual Quality Assurance Assessment (AQAA) completed by the manager has been used as a source of evidence in this report. At the time of writing this report we had received four completed surveys from residents, and five from staff. Information from these have been used throughout the report. People who use the service prefer to be known as residents, therefore this term of reference has been used throughout this report. We would like to thank the manager, staff and residents for their cooperation during this site visit. Feedback was provided to the manager before she left the home for the day. 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. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 27 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 27 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 who use the service are provided with the written information they require to enable them to make a choice about living at the home. Assessment documentation is in place to ensure the individual needs of residents can be met. Evidence: The home has a Statement of Purpose and a Service User Guide that were both reviewed in May 2008. These documents included the mission statement, aims and objectives of the service, philosophy of care, terms and conditions, complaints information, the managers experience and qualifications and a summary of the qualifications of staff working at the care home. The Statement of Purpose clearly states that the home is for retired Christian Scientists who need a care home. All surveys returned from residents informed that they did receive enough information about the home before they moved in. Care Homes for Older People Page 10 of 27 Evidence: The pre admission assessment for a recent admission to the home was viewed. This included information in regard to their personal care, dressing, diet, sight, hearing communication, oral care, foot care, mobility, dexterity, history of falls, continence, mental state, cognition, social interests, hobbies, religious and cultural needs, personal risk and safety. The assessments had been signed and dated by the manager. The manager told us that an information pack is sent to prospective residents when they first enquire about the home. They have to be practicing Christian Scientists. The manager visits the prospective resident at their home where an assessment of their needs is undertaken. Residents are encouraged to visit the home, and to stay from two to four weeks, after which residents decide for themselves if the home would be suitable for them. During discussions residents told us that they had assessments undertaken and they had to agree that according to their religious beliefs, they would not seek to use any medical intervention during their life at the home. The Annual Quality Assurance Assessment (AQAA) informs that assessments of prospective residents are undertaken, and they consider carefully whether the home can meet the needs of applicants prior to admission. Care Homes for Older People Page 11 of 27 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 who use the service have care plans and risk assessments in place that ensure their physical and health care needs are met. Residents are practicing Christian Scientists and will not receive medication. Evidence: Three care plans were viewed during the site visit. Care plans included information in regard to residents personal, social and health care needs. Care plans viewed had been signed and dated by the resident, and reviews had taken place. Daily notes were evidenced and these also included notes of night time. It was evident from discussions that staff were aware of the contents of care plans and the need for review. Staff told us that they read all the care plans when they come on duty, this was evidenced during the site visit. Discussions took place with the manager as we were told that care plans are usually reviewed every two to three months. The manager was advised that care plans should be reviewed every month. Care plans viewed had risk assessments for daily living including walking, dressing, Care Homes for Older People Page 12 of 27 Evidence: mobility and travelling, and had been reviewed during the last twelve months. However, risk assessments require further developing and to include more information in regard to manual handling and falls. A recommendation has been made in regard to this. Surveys returned from residents informed that they receive the care and support they need. The home is a Christian Scientist home and does not use medical interventions. The Christian Science Practitioner and Nurse support residents to focus on the spiritual ideas and healing on their affliction or injury. Records of contact with these people are recorded in the care plans. Residents told us that should they not respond positively to the prayer and require hospitalisation, they would first be offered nursing care in a related home, if suitable, or after consultation with any existing family a release document would be signed permitting a transfer from the home to a suitable hospital or other facility. After recovery they would be readmitted to the home. During discussions staff told us that they respect residents privacy and dignity through knocking on bedroom doors, calling residents by their preferred names and providing personal care in the privacy of their bedrooms and bathrooms. This was also confirmed during discussions with residents who stated that staff always treat them in a respectful manner. The AQAA informs that residents are active around the home and they actively encourage mobility. Their privacy and dignity are preserved and staff are aware of the requirement to deal respectfully with the residents. Care Homes for Older People Page 13 of 27 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 who use the service are provided with opportunities to improve their lifestyle, and where possible they are able to maintain contact with family. Special dietary needs are catered for and meals are varied with individual choices ensuring that residents receive an appealing and balanced diet. Evidence: The home employs an activity coordinator who works on Tuesdays, Thursdays and Saturdays. Activities provided include taking part in the daily bible based group discussions; silks painting that was beautiful, making beaded necklaces and cards for all seasons. Each resident is provided with weekly-proposed activities. A poetry reading was planned for the afternoon of the site visit and the Expert by Experience visited one resident who kindly read a poem they had composed for the event. It was moving in its content. One resident plays the piano and provides music activities during the week. External trips are organised and outside entertainers also visit the home. Surveys received from residents informed that activities are arranged by the home. Care Homes for Older People Page 14 of 27 Evidence: Most residents have contact with their family and friends and are able to go out with them if they wish to. Some residents told us that because the care home is not local to their former home, and due to their age, there are no relatives available to take them out, but despite this, residents were content with their in house family. Residents can attend the Christian Scientists Church every Sunday. Some residents told us that their home church was in London so they did not feel the need to attend the local church. During discussions staff told us that residents make their own decisions every day. This was confirmed during discussions with residents who told us that they choose their clothing and the time they rise each morning. They choose the content of their breakfast and whether they eat it in bed or in a chair in their own room. The home uses a six-week menu that includes meat, fish, pasta, fresh vegetables and fruit. Residents told us that they are provided with drinks and snacks throughout the day, which was observed during the site visit. Qualified chefs are employed and suitable varied quality meals are offered daily. The menu is displayed on a notice board in the hall and should they wish to, residents speak to the chef about personal changes from the offered menu. On the day of the inspection the main dish was liver and bacon and vegetables. One resident had exercised her choice and had a quantity of bacon freshly grilled instead of liver and bacon. Choices from the sweet course were individually offered and included peaches, with custard and cream and/or rice pudding or a cornetto. The meal was accompanied by water or fruit juice and followed by coffee for those who required it. After their lunch most residents went to their rooms for a quiet rest seeming content with their lunch. There would be afternoon tea (twice a week with cakes) and another meal at 5.45. The residents however did not appear overfed. Surveys received from residents informed that that they like the meals at the home. The AQAA informs that residents have quite a say in the way they would like things to be run. They have substantial input into the activities provided, and the food they are offered. Care Homes for Older People Page 15 of 27 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 have access to a satisfactory complaints system that enables residents and their families to raise concerns. Staff having training and an understanding of adult protection issues protects residents. Evidence: The Commission For Social Care Inspection has not received any complaints in regard to the home since the last inspection. The home has a Complaints Policy and Procedure that includes the timescales for responding to the complainant, and the Commission For Social Care Inspection contact details. This document was last reviewed in May 2008. This is clearly displayed on the notice board and a copy is included in the Statement of Purpose and Service User Guide. Information provided in the AQAA informed that the home has not received any complaints during the last twelve months. During discussions one resident told us that they would talk directly to the manager if they had any concerns, but have not had the need to do so. Surveys returned by residents inform that they know how to make a complaint. Staff at the home follow the organisations Protection of Vulnerable Adults Policy and Procedure that is due to be reviewed on the 10th March 2008. The home has a copy of Care Homes for Older People Page 16 of 27 Evidence: the recent Surrey Multi-Agency Safeguarding Procedures available in the office for staff to read. During discussions, staff gave an account of who they would report suspicions of abuse to, and stated they would not hesitate to report bad practice. Staff told us they had received training in regard to the Protection of Vulnerable Adults and read the Policies and Procedures in regard to this area. Scenarios in respect of abusive situations were discussed with two members of staff. They were able to demonstrate an understanding of Safeguarding Adults issues and the procedures to be followed. The manager told us that all staff had last attended training in regard to Safeguarding Adults on the 6th June 2008. New staff receive this training in their induction training. Evidence of the dates the manager had acquired for staff to attend training in 2009 were seen during the site visit. The Commission For Social Care Inspection made one Safeguarding referral in regard to the home during the last twelve months. The manager told us that they had learnt a lot from this experience. The AQAA informs that residents know if they have any concerns they can go straight to the manager or head of care, and that their concerns would be taken seriously and acted upon. There was no information in the AQAA in regard to Safeguarding. This was discussed with the manager and further comments have been made under the Management and Administration section of this report. Care Homes for Older People Page 17 of 27 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 location and layout of the home is suitable for its stated purpose. It is accessible with a pleasant and homely atmosphere; however, identified issues must be addressed to ensure residents continue live in a safe and well-maintained environment. Evidence: A tour of the premises and the sampling of residents bedrooms were undertaken during the site visit. The accommodation is set over two floors that are accessed via a passenger lift and stairs. Currently there are fifteen bedrooms with en suite facilities, two have showers and two have baths. One bedroom that does not have an en suite facility has been converted into an activity room and library. The manager told us that if the home became full this room would become a bedroom again. Bedrooms sampled during the site visit were appropriately furnished and residents had their own personal belongings around them including their own furniture, family photographs and televisions. Residents told us they like their bedrooms and having their own belongings around them. The home is situated in good-sized grounds with a well-maintained garden to the rear of the property. The home is close to the local shops and community facilities. There are ample car parking facilities to the front of the home. Care Homes for Older People Page 18 of 27 Evidence: There is a laundry and sluice room on the ground floor, however, the sluice room requires a lock fitted to ensure the safety of residents. There is a dining room and a lounge that are appropriately furnished. New carpets had recently been fitted and a new boiler had recently been installed. The home was warm and comfortable, however, the manager must address the following hazards in regard to the environment. There were some curved radiators that had not been covered and were hot to touch in the identified bedrooms. The manager told us that this had not been undertaken due to the cost and shape of the radiators. The manager must ensure these are made safe to touch. There were also exposed hot water pipes that require covering. The enamel covering of the bath on the first floor is heavily stained and requires attention. A requirement has been made in regard these. There are trailing electric wires in bedrooms that cause a trip hazard for residents, and some first floor windows did not have any restrictors fitted. The bathroom on the ground floor requires attention to the decor as paint was peeling away from part of the ceiling, the wooden ledge beside the bath has water damage and requires replacing. This bathroom also has a frosted window but does not have a blind fitted to ensure full privacy for people who use this bathroom. A requirement in regard to this bathroom has been made. Surveys returned from residents informed that the home is always fresh and clean. On the day of the site visit the home had a homely atmosphere, was very clean, tidy and free from offensive odours. Care Homes for Older People Page 19 of 27 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. The arrangements for staffing are satisfactory, ensuring staff have the qualities and training to meet the needs of residents. Recruitment procedures ensure that people who use the service are fully protected. Evidence: The manager told us that she had undertaken a review of the staffing levels for the home, and is confident that there is enough staff on each shift to meet the assessed of the current eleven residents. However, if the numbers increased to fourteen then a further review of the staffing levels would be undertaken. The staffing structure for the home consists of the manager, head of care, and seven care staff, cook, domestic staff and a maintenance man. The duty rota for the week of the site visit was viewed. The staffing arrangements remain the same as reported in the previous inspection report. There are two care staff on duty in the morning as well as the registered manager. In the afternoon there is only one member of staff between the hours of 11.00 and 15.00. The manager told us that the housekeeper is also a carer and is available in the case of an emergency. The manager and head of care cover all the on call duties. The manager told us that of the seven care staff, two hold the NVQ level 2, two are Care Homes for Older People Page 20 of 27 Evidence: working towards the NVQ level 3 and are due to complete these in January 2009, and three are working towards the NVQ level 2. Therefore the home will have achieved the minimum of fifty percent of staff holding the NVQ level 2 and above when these staff have completed the courses. Two recruitment files were viewed during the site visit. These included the documents required however, the dates of employment and interview notes should be maintained in the files. The manager told us that one member of staff had left but recently returned to work at the home. The old Criminal Record Bureau check from 2006 was being used, but the manager has since submitted another application for this. Evidence was viewed that a Protection Of Vulnerable Adults (POVA) check had been received, but they were still waiting for the CRB check to be returned. The manager was reminded that this person must not work unsupervised until they have received this. The manager told us that the organisation is receiving advice from a private personnel company to look at and advise the home on their recruitment procedures and documentation. The home continues to use agency staff. The requirement made at the last inspection, that the home must obtain from the supplying agency evidence that the appropriate recruitment checks have been conducted, has been complied with. The organisation has a staff induction book that is in line with the Skills For Care Council induction standards. Surveys returned from staff informed that the induction they received covered everything they needed to know to do their job when they started. The manager told us that there was not a current training and development plan, however, this is to be attended to. Care Homes for Older People Page 21 of 27 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 arrangements for management and administration ensure the home is run in the best interests of residents, and their safety is promoted and safeguarded. The manager must attend to the identified issues raised in this report in regard to the environment. Evidence: The manager has told us that she has been working at the home for five and half years. She is a trained Christian Scientist Nurse and has completed the NVQ level 4 and Registered Managers Award (RMA). Other training undertaken by the manager during the last twelve months include health and safety, food hygiene and handling, Infection Control, fire safety and Safeguarding Adults. During discussions, staff informed the Inspector that the manager has an open door policy, is approachable and supportive. Staff stated that they receive supervision every two months, which was verified through the records maintained at the home. Care Homes for Older People Page 22 of 27 Evidence: Quality assurance is undertaken through meetings with residents. Minutes of these meetings were sampled during the site visit. Meetings are also held with residents and their relatives. Annual surveys are undertaken to ascertain the views of residents and their relatives. The last survey was undertaken in June 2008. The manager told us that residents and their families are responsible for their finances. The home holds small amounts of money for residents that are kept secure. Records of monies held were sampled for two residents. The records balanced with the money held in the individual accounts. The manager sent the Annual Quality Assurance Assessment to the Commission For Social Care Inspection when we asked for it. Although this document was informative, there were some omissions, and some outcome areas require further information. This was discussed with the manager and a recommendation has been made that the manager should read the guidelines in regard to completing the AQAA that are on the CSCI web site. During discussions staff told us that they receive formal one to one supervision every two months, and an annual appraisal. This was confirmed through viewing the supervision dates and surveys returned from staff. The sampling of training records evidenced that staff are receiving the mandatory training as required. The manager told us that the home has their own DVD for training, however, during the next twelve months this training is to be provided from external trainers. The AQAA informs that the maintenance of equipment is tested as per the recommendation made by the manufacturer or other regulatory bodies. The following records were viewed during the site visit. The passenger lift, 19.8.08, Environmental Health Office visit, 30.10.08, call bells, 29.9.08, Legionella, 18.3.08 and fire alarms, 23.4.08. The home has risk assessments in place that include the kitchen, bathroom, Control Of Substances Hazardous to Health (COSHH), laundry room, washing machine and wheelchairs. Care Homes for Older People Page 23 of 27 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 24 of 27 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 1 21 12 The registered person shall 02/01/2009 make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of residents. The ground floor bathroom must have a blind fitted to the window to ensure the privacy and dignity of people using it is maintained. The identified bath on the first floor is badly stained and requires attention. 2 25 13 The registered person shall ensure that unnecessary risks to health and safety of residents are identified and so far as possible eliminated. The identified first floor bedrooms must have window restrictors fitted. Identified radiators and hot 02/01/2009 Care Homes for Older People Page 25 of 27 water pipes must be covered or made safe. Trailing electric wires must be made safe. 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 2 7 33 Risk assessments should be further developed to include more information in regard to manual handling and falls. The manager should read the guidelines on the CSCI web site in regard to completing the Annual Quality Assurance Assessment. Care Homes for Older People Page 26 of 27 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.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). 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