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Inspection on 10/08/09 for Blackwell Vale Nursing Home

Also see our care home review for Blackwell Vale Nursing Home for more information

This inspection was carried out on 10th August 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

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 manager ensures she only admits to the home those people whose assessed needs can be fully met. The needs of those already living in Blackwell Vale are also taken into account when assessing any prospective resident. There is an appropriate admissions procedure that ensures the settling period for the new residents is as easy and relaxed as possible. All healthcare needs are met by qualified nurses, the residents` own doctors, visiting opticians and chiropodists. Medicines are managed correctly with records up to date. Staff work well with the residents showing patience and understanding. Comments received from residents and families included, `I like it here and the staff are lovely`, I can find no faults`, they take into account my mother`s dementia and look after her very well` and As far as my mother is concerned I don`t think they could do any better`. Comments from a senior practitioner (adult cultural services) commented that `the home tries to improve all aspects of life in the home. I feel that, on the whole, Blackwell Vale try their hardest to provide quality care to the residents. The manager has high standards she endeavours to maintain. Person centred planning is being introduced and all residents have an up to date plan of care based on the initial assessment and the residents wants and preferences. People living in the home are supported to have their own preferred lifestyle and there are organised activities for those wishing to join in. There is a procedure for dealing with complaints and any adult protection issues with the manager keeping us up to date about any issues raised. Blackwell Vale provides, in the main, a safe comfortable environment. The building is reasonably well maintained but the organisation does need to keep on top of decoration and refurbishment. All rooms are now used only for single occupancy, which helps to preserve privacy and dignity. The staff work together as a team and support the manager in her role. There is a full recruitment and selection procedure in place. This helps to ensure only suitable people are employed to care for those using this service. There is an internal quality assurance st stem in place that enable staff, residents and family members to give their opinions about the service provided.

What has improved since the last inspection?

The front garden has been improved and now provides a pleasant sitting area. Some re--decoration has been completed and new profiling beds have been purchased. A new care planning format has been introduced giving a more person centred approach to the care provided.

What the care home could do better:

We want the manager and staff to continue to ensure each resident has a person centred care plan by transferring all the relevant information to the new format. There is still work to be carried out to ensure the environment is improved and meets the National Minimum Standards. The rear garden area needs clearing as this is very overgrown with paths not visible at all. The removal of the builders skip should be actioned as soon as possible. Some landscaping would make this area more suitable for residents` use. Arrangements must be made to replace the sluices as there have been no working sluices in the home for some time. The organisation should provide a choice of bathing facilities for the residents as currently there are only showers available for use. Although there are assisted baths in the home none of them were operational on the day of our visit and assisted bathing should be available for all those living in the home. Requirements were made regarding the sluices and the baths. Although it may be difficult the manager should continue trying to recruit first level nurses that are qualified in dementia care. In the meantime she should arrange for some specialist training in this subject for the qualified staff already employed at the home.

Key inspection report Care homes for older people Name: Address: Blackwell Vale Nursing Home Rear 61 Durdar Road Carlisle Cumbria CA2 4SE     The quality rating for this care home is:   one star adequate 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: Margaret Drury     Date: 1 0 0 8 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: Blackwell Vale Nursing Home Rear 61 Durdar Road Carlisle Cumbria CA2 4SE 01228512456 01228810994 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): www.fshc.co.uk Laudcare Ltd (a wholly owned subsidiary of Four Seasons Health Care Ltd) care home 60 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The registered person may provide the following category/ies 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 (maximum number of places: 28) Dementia - Code DE (maximum number of places: 32) The maximum number of service users who can be accommodated is: 60 Date of last inspection Brief description of the care home Blackwell Vale Care Home is owned by Four Seasons Health Care Limited and is located on the outskirts of Carlisle near to the racecourse. There is a bus stop nearby and ample car parking is provided. The home is divided into three areas with the ground floor providing nursing care for service users within the category of registration of Older People. The second floor accommodates and provides nursing care for people with Dementia. The home was purpose built and each unit has its own lounge and Care Homes for Older People Page 4 of 28 32 0 Over 65 0 28 Brief description of the care home dining room. There is a conservatory and two other lounge areas on the ground floor. Fees payable at the home vary according to the level of care required and can be discussed with the manager. There are additional charges for hairdressing, private chiropody, personal newspapers and magazines, toiletries and taxis for personal travel. The home makes information about its services available through its own brochures, its service user guide and statement of purpose. These are available within the home. This home does not provide intermediate care. 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: one star adequate 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 was the main or key inspection of this service and information was gathered in a number of ways. We sent the manager an Annual Quality Assurance Assessment (AQAA) and she returned this to us, The Care Quality Commission (CQC) within the timescale required. It is a legal requirement that this document is completed every year by every registered provider. The document outlined what improvements had been made in the last 12 months and what plans are in place for the next 12 months. Two inspectors, Margaret Drury and Marian Whittam made an unannounced visit to the home that lasted just over 6 hours. During that time we toured the building, spoke to residents and staff and discussed the running of the home with the registered manager. We looked at a sample of care plans, medication records, staff files and maintenance records. We had sent out surveys to staff residents and families and the observations made on the replies are included in this report. We looked at the complaints records and procedures and checked any adult protection Care Homes for Older People Page 6 of 28 documentation. We also took into account the information submitted to CQC through records of incidents the manager had sent to the Commission. 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: We want the manager and staff to continue to ensure each resident has a person centred care plan by transferring all the relevant information to the new format. There is still work to be carried out to ensure the environment is improved and meets the National Minimum Standards. The rear garden area needs clearing as this is very overgrown with paths not visible at all. The removal of the builders skip should be actioned as soon as possible. Some landscaping would make this area more suitable for residents use. Arrangements must be made to replace the sluices as there have been no working sluices in the home for some time. The organisation should provide a choice of bathing facilities for the residents as Care Homes for Older People Page 8 of 28 currently there are only showers available for use. Although there are assisted baths in the home none of them were operational on the day of our visit and assisted bathing should be available for all those living in the home. Requirements were made regarding the sluices and the baths. Although it may be difficult the manager should continue trying to recruit first level nurses that are qualified in dementia care. In the meantime she should arrange for some specialist training in this subject for the qualified staff already employed at the home. 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 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their care and support needs assessed before they move into Blackwell Vale so they know their needs can be met. Evidence: The home has a Statement of purpose that forms part of a welcome pack given to those wishing to move in. This document is now produced on a compact disc and is also available in other languages if requested. We looked at a sample of residents files and noted that an in depth assessment of need is completed as part of the admission process. The manager is very mindful of the needs of those people already living in Blackwell Vale when assessing any prospective residents. Those wishing to move in are invited to look around the home but in general this is done on their behalf by a family member. This does give the opportunity of meeting the staff and the other residents. Comments on returned survey forms confirmed that family members received sufficient information about the home to enable them to make an informed decision about taking up the offered place. Care Homes for Older People Page 11 of 28 Evidence: The initial assessment of needs covered areas such as personal care and well-being, healthcare needs mobility, current medication and social interests. Many of those living in Blackwell Vale have also been assessed by a social worker and there were copies of this documentation on file. All residents have a contract with the home. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The healthcare needs of people living at Blackwell Vale are well managed to ensure they receive the care and attention they need. Evidence: Each resident has a plan of care that is generated from the initial assessment of needs. We were able to read a range of the plans and found them to be informative and up to date. The home has introduced a new person-centred format and the staff are in the process of transferring the information from the existing format to the new. This gave the opportunity to view both. We read some plans in depth for people we had observed or spoken to but also selected some at random. We found that all the care plans were up to date and reviewed at least monthly. If there was any change in circumstances at all changes were made to the way in which care was provided. The new format focussed very much on the strengths, preferences and needs of the residents and looked at the way in which people wanted their care to be delivered. Short time care plans for specific needs are put in place if needed. The care plans and other records evidenced that people received visits from their Care Homes for Older People Page 13 of 28 Evidence: doctors when needed. Optical and chiropody services are provided regularly but it is not always possible to access dental treatment. There are aids about the home to assist with moving and handling and mobility. People ar provided with pressure relieving mattrasses and profiling beds to reduce the risk of pressure sores and continence aids are available. Nutritional screening is in place and weights are checked and recorded. The receipt, administration, recording and disposal of medicines were managed correctly and evidenced good practice. All records were up to date and all controlled drugs were correctly monitored and recorded. A new medication room is currently being completed. This room was originally a bathroom and is being converted. This will give improved facilities for the receipt, storage and disposal of medication. Observations throughout the day showed that those living in the home were cared for in a warm, caring way. Comments on returned surveys included, The home looks after my mother very well and keeps me informed of her medical condition, As far as my mum is concerned they could not do better and The home looks after my Nana very well with excellent nursing care. Dignity and privacy are maintained at all times and all personal care is delivered in the privacy of residents rooms. Unfortunately at the time of our visit there were no bathrooms in use due to the assisted baths being out of commission. This meant that residents did not have a choice with regards to personal bathing. If they were unable or did not wish to take a shower the only alternative was a full body wash. The organisation needs to address this problem as soon as possible. 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 using this service receive the support they need to live their chosen lifestyle. Evidence: The activities programme has improved since the last inspection and there were details of the programme on display around the home. There are 3 part time activities co-ordinators employed to ensure there is a varied programme on offer to those wishing to join in. We were able to observe some residents enjoying time with the coordinators during our visit and also speak to one of them. She told us that she really enjoyed her job and it was obvious that she knew the residents she was spending time with. Daily routines are flexible and reflect peoples changing needs, with some people enjoying time in the communal areas whilst others remained in their rooms. The home encourages visitors and we were advised that there is no restriction on when people can visit the home. Comments from one relative on a returned survey included, The home looks after my mother as a guest and me as a worried relative. Residents said their families were always made welcome and offered refreshments. There is a monthly news letter that is very popular with residents and visitors alike as they all find it very informative. There are church services for those wishing to attend and ministers will also visit on request. This ensures the spiritual needs of those living in the home are met. Care Homes for Older People Page 15 of 28 Evidence: We were able to inspect the kitchen area and speak to one of the chefs during our visit. The kitchen was clean and tidy with all the required records in place and up to date. There are 2 chefs covering the 7 day week with kitchen staff to support them. The menus showed mainly traditional dishes although the chef, who confirmed that he spoke with residents daily, said he would try any dish requested. The daily menu was displayed on the dining tables along with the alternative dishes that could be chosen. The kitchen was well stocked and all cakes and pastries are home made. Both chefs work a full day so there is no need for care staff to prepare any meals. Menus are updated seasonally and the catering staff are always looking for new ideas from the residents about meals they would enjoy. Care Homes for Older People Page 16 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 using this service are protected by the complaints and safeguarding procedures, which were understood by the staff. Evidence: The service has a complaints procedure in place with copies on display in various places. There is also a copy included in the welcome pack. There is a procedure to follow and staff we spoke to confirmed that they were aware about what to do if they received a complaint. All the comments on the returned survey forms confirmed that residents or their families did not see the need to complain but if they did they knew who to speak to and were confident their comments would be listened to and any action take. There is a complaints log in place and there have been 2 to record in the last 12 months. These were recorded, investigated and settled in the correct manner. There are policies and procedures in place to safeguard people from harm and abuse and staff do receive regular training from the manager. Staff we spoke to were confident that they knew what to do should the occasion arise. There have been some incidents between residents that have been referred to Adult Social Care and as far as the home is concerned these have all been recorded and dealt with in the appropriate way. The manager always ensures she notifies The Commission about any such incidents under regulation 37 of the Care Standards Act. The manager also has a copy of The Cumbria multi-agency guidelines for safeguarding to refer to if needed. Currently all adult protection training is completed by the manager in-house and we Care Homes for Older People Page 17 of 28 Evidence: did suggest that some external training could be accessed that may be useful for staff. Care Homes for Older People Page 18 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 adequate 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 home that is generally clean, comfortable and tidy. However the limited bathing facilities may mean that there is little freedom of choice for those living in Blackwell Vale. Evidence: Blackwell Vale is situated on the outskirts of Carlisle with direct public transport links into the city centre. The home is purpose built and situated over 2 floors with a lift giving access to the upper floor. Although some of the rooms are registered to accommodate 2 people sharing, the manager has made a decision to use all registered rooms for single occupation only. There is ample communal space on each floor with extra provided by a conservatory and other lounge space on the ground floor. Some areas of the home have been decorated since the last inspection as have a number of residents rooms. An air conditioning unit has been installed on the top floor, which has made the temperature more acceptable. On the whole the general environmental standards were reasonable although some parts were looking a little tired and needed some attention. Residents rooms were bright and clean and personal to each resident with items brought from home. There are communal bathrooms and toilets throughout the home but all of the baths were not operational and therefore not fit for purpose. This means that those living in Care Homes for Older People Page 19 of 28 Evidence: the home have little or no choice about bathing as the choice is limited to a shower or complete body wash. This situation is not acceptable and should be addressed as soon as possible. There were also tiles missing from the wall in one of the toilets making the wall surface rough and dangerous to those using it. These must be replaced for both health and safety reasons. Since the last inspection work on the garden area at the front of the building has been completed and this area is now pleasant and suitable for sitting. However the back garden now needs attention. It was extremely overgrown and unusable for residents or visitors. The paths were very overgrown and there was a builders skip in one corner. The manager has a clear vision of how she wants the grounds to look and the organisation is aware of this. Attention should be given to this as soon as possible. The home employs a maintenance manager who is always on hand to repair or fix any problem. We spoke to him during our visit and he was able to show us all his records as he was completing all the temperature and fire safety checks on the day of our visit. His records were extremely well kept and all up to date. We were able to observe and speak to domestic staff during our visit. The home was very clean and sweet smelling and the staff advised that there is always a plentiful supply of cleaning materials for them to use. However, on the day of our visit we were advised that there were no sluicing facilities in use and this could lead to cross infection. the manager did confirm that she expected 2 sluices to be installed in the near future Care Homes for Older People Page 20 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. People using this service are protected by an appropriate recruitment procedure although lack of staff trained in dementia care may mean some individual needs may not always be met. Evidence: We looked at the off duty rotas for staffing in the home and we discussed the staffing arrangements with the manager. The home is currently understaffed as there are 5 members of the staff team on long term sick leave. However the manager does manage the situation as well as she is able by using agency staff. It is always the same agency and usually the same people so there is some continuity of care. It is not always easy to recruit staff especially first level nurses who are qualified in dementia care and the manager has recently tried to recruit staff, including a deputy manager, but was unsuccessful. However we could see from the rotas that there was always the correct number of staff to care for the residents at all times. Blackwell Vale follows the organisations policies and guidelines when recruiting staff and this was evidenced when we looked at a sample of staff files. We noted that all the necessary preemployment checks had been completed prior to the person starting work. The checks included, the completion of an application form, attending for interview, provision of 2 references and the completion of an enhanced Criminal Records Bureau check. This procedure helps to protect the residents and ensure that only suitable people are employed to care for vulnerable people. Care Homes for Older People Page 21 of 28 Evidence: Staff training is ongoing although much of it is completed in house by the manager. We did recommend that some external training in adult protection be accessed for staff. We also recommended that the manager look to accessing some external, specialist training in dementia care as there are currently no registered mental health nurses employed at Blackwell Vale. Other completed training included, adult protection (internal), manual handling, COSHH, infection control, fire safety and customer care. Staff have access to National Vocational Qualification training in social care and there is 48 of staff already qualified to level 2 with the senior carers to level 3. We observed the interaction between staff and residents and found it to be warm and friendly whilst still respecting residents dignity. Comments on the returned survey forms indicated that staff were happy working at Blackwell Vale and that they all worked as a team to care for all those living in the home. Care Homes for Older People Page 22 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Blackwell Vale is run by an experienced and qualified manager but there are health and safety issues that could affect the well being of those living there. Evidence: The manager of this service, Helen Smallbone, is suitably qualified and experienced in the care of older people. Although there is currently no deputy manager she is supported in her role by a staff team of first level nurses and experienced support workers. She keeps her practice up to date and, as a trainer, is able to organise staff training in a variety of subjects. She has recently completed a 5-day management course. She has a definite vision for the home and assured us she passes on all her plans to her line manager for attention. Comments on the returned surveys from residents, families and staff evidenced that she has a high profile in the home, is well known and works with an open door policy for anyone wishing to speak to her. There was a warm and inclusive atmosphere in the home during our visit evidencing that the manager and staff have the best interests of those living there at heart. The residents we spoke to all agreed they were able to speak to her when they wanted, this being Care Homes for Older People Page 23 of 28 Evidence: made easier as she completes 1 care shift each week. There were, however a couple of issues that did give cause for concern. Although requests had been made on more than one occasion we discovered that the home had been without a working sluice for almost 2 years. This situation is not acceptable as it increases the possibility of cross infection. We requested that the manager ensured sluices were installed as soon as possible. She did confirm that she thought two sluices would be installed in the near future. She had also, on more that one occasion, requested that the out of order baths be replaced and we did make a requirement that the request be made again as a matter of urgency. The replacement of the baths is necessary for the health, safety and welfare of those currently living in Blackwell Vale. It is also important that residents are given a choice about their bathing prefrences. We saw that there were suitable policies and procedures in place for the handling of residents personal finances with the records being in place and up to date. Regular audits are completed by the manager and her regional manager. All records to do with the running of the home such as, fire safety checks, water temperatures, fire alarms and call bells were in place and up to date. All equipment is serviced under annual agreements and there records to evidence this. There are good systems in place to measure quality outcomes in all areas of the home with the manager preparing a report after all the annual surveys are received. Any action required from the annual quality audits are discussed with her line manager. Staff are appropriately supervised to support their personal and professional development. There are records on staff files to evidence this practice. Care Homes for Older People Page 24 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 25 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 1 21 23 The walls in the toilet must 30/10/2009 be re-tiled to ensure the wall surface is safe and clean. To ensure residents ae safe from injury and to avoid cross infection. 2 21 23 It is required that the home provide suitable and operational baths. To ensure all residents are able to choose what kind of bathing facility they prefer 30/10/2009 3 38 23 Sluicing facilities are made available as soon as possible. To reduce the possibility of cross infection 11/09/2009 Care Homes for Older People Page 26 of 28 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 19 30 It is recommended that the rear garden area be made suitable for residents use as soon as possible. it is recommended that external training in dementia care be provided to the qualified staff employed at Blackwell Vale. 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. 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