Inspection on 21/10/08 for Brookdell Retirement Home

This inspection was carried out on 21st October 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brookdell Retirement Home 12/01/09

Brookdell Retirement Home 21/11/06

Brookdell Retirement Home 15/11/05

Brookdell Retirement Home 23/05/05

Brookdell Retirement Home 25/01/05

Brookdell Retirement Home 19/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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: Brookdell Retirement Home Foreside Barrowford Nelson Lancashire BB9 6AE     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: Julie Playfer     Date: 2 1 1 0 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 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) 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 28 Information about the care home Name of care home: Address: Brookdell Retirement Home Foreside Barrowford Nelson Lancashire BB9 6AE 01282603224 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Anna Mary Nicholson Type of registration: Number of places registered: Mr Derek Howard,Mrs Doreen Howard care home 15 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The registered person may provide the following category of service only: Care Home only - Code PC 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 The maximum number of Service Users who can be accommodated is: 15 Date of last inspection Brief description of the care home Brookdell is registered to provide accommodation and personal care for up to 15 older people over the age of 65. The home is a mature detached property offering homely accommodation, surrounded by private, attractive and accessible gardens. Garden furniture is provided, for the residents use in fine weather. The home is located in a fairly secluded position, away from the centre of the village. Accommodation is provided in five single rooms and five shared rooms, which are located on two floors. Care Homes for Older People Page 4 of 28 Over 65 15 0 Brief description of the care home Access to the first floor is by chair lift. Communal space is provided in two inter connecting lounge/dining rooms. Various aids and adaptations to assist with mobility and self-help skills are available. At the time of the inspection, the fee was £372.00 per week. Additional charges were made for hairdressing, chiropody, tickets/holidays and personal magazines and newspapers. Information was made available to prospective residents by means of a statement of purpose, service users guide and brochure. The brochure was usually given to prospective residents and/or their relatives on viewing the home or at the point of assessment. The service users guide was displayed in each bedroom. Copies of previous inspection reports can be obtained from the home or from the Commissions website at www.csci.org.uk Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: A key unannounced inspection, which included a visit to the home was conducted at Brookdell on 21st October 2008. The previous key inspection took place on 21st November 2006 and an annual service review was carried out on 20th December 2007. There have been no additional visits to the home since the last key inspection. At the time of the visit there were 15 people accommodated in the home. The inspection comprised of spending time with the residents, looking round the home, reading some of the residents care records and other documents and talking to the staff and the registered manager. As part of the inspection process we (the commission) used case tracking as a means of gathering information. This process allows us to focus on a small group of people living at the home, to assess the quality Care Homes for Older People Page 6 of 28 of the service provided. Prior to the inspection, the registered manager completed an Annual Quality Assurance Assessment known as AQAA, which is a detailed self assessment questionnaire covering all aspects of the management of the home. This provided useful information and evidence for the inspection. Satisfaction questionnaires were sent to the home for distribution to the staff and the residents. Nine questionnaires were returned from people living in the home and eight questionnaires were received from staff. The responses from the questionnaires were collated and used throughout the inspection process. What the care home does well: What has improved since the last inspection? Since the last inspection, the format of the pre admission assessment of needs had been updated, to include a section on safety and colour coded highlighted areas, which drew the staffs attention to specific needs. This meant the registered manager could be confident that a persons needs could be met in the home and the staff had detailed information about what help and assistance people needed. Various improvements had been made to the premises. These included repairs to the kitchen units and redecoration of one bedroom. New wardrobes had also been purchased for one of the bedrooms. Care Homes for Older People Page 8 of 28 The staff induction had been revised and up dated to include the skills for care standards, which meant that new staff had completed an induction to nationally recognised criteria. The registered manager had also completed NVQ level 4 in care, which meant that the manager had all the necessary qualifications to carry out her role effectively. An action plan had been produced following the results of the satisfaction survey. This meant the residents and their relatives were assured that the manager had listened to all comments and they were aware of what actions the manager was taking. 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 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 living in the home had their needs properly assessed and they were provided with appropriate written information to enable them to make an informed choice about where to live. Evidence: Written information was available for residents in the form of a statement of purpose and service users guide. The guide had been distributed to residents and was available for reference in each of the bedrooms. People spoken to confirmed they had received a copy of the service users guide, which they said was easy to read and understand. A brochure had also been produced which offered current and prospective residents with an overview of the services and facilities. All the residents who completed a questionnaire indicated they had received enough information prior to moving into the home. Copies of the last inspection report were available for reference within the statement of purpose file in the hallway. Care Homes for Older People Page 11 of 28 Evidence: From the personal files seen it was evident that the residents had been issued with a contract. The contracts had been signed by the residents and/or their representative and included information about the level and payment of fees and the rights of the residents. The contract was easy to read and was presented in a clear format. This meant that residents were aware of the terms and conditions of residence and knew what they could expect from the service. The case tracking process demonstrated that the residents had their needs assessed prior to admission by a social worker and/or the manager or a member of the staff team. Copies of the preadmission assessments covered a range of individual needs including personal, social, health and cultural needs. The registered manager confirmed that admissions were not made to the home in the absence of a full needs assessment. This meant the registered manager could be confident that the staff had the necessary skills and knowledge to meet the assessed needs of prospective residents. Since the last inspection, the assessment format had been updated to include a section on safety and a colour coded highlighter which drew staffs attention to particular needs and risks. Copies of letters were seen on the residents files to indicate the registered manager had informed prospective residents that having considered the assessment, their needs could be met in the home. This meant residents could be assured that the home was a suitable place for them to live. The registered manager said that prospective residents were invited to spend as much time as they wished in the home prior to making the decision to move in. This enabled the person to meet other residents and staff and experience life in the home. Further to this one person wrote in a questionnaire, We knew when we arrived through the door, that this was the place to be, we loved it. Following admission, the contract stated that a trial period of four weeks was offered to every new resident, so both parties could make sure the placement was successful and the residents individual needs could be met. 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 health and personal care received by residents was based on their individual needs. Care practice took full account of the residents privacy and dignity. Evidence: Three peoples files were looked at in detail as part of the case tracking process. All three files seen contained a care plan, which was based on the persons assessment of needs. Personal profiles had been incorporated into the care plan documentation, which provided details about past life experiences and important events. This information was useful for staff to stimulate meaningful conversation with the person. The plans were supported by daily records of personal care, which provided information about changing needs and any recurring difficulties. The records were detailed and the residents needs were described in respectful and sensitive terms. The care plans covered the residents personal, social, health and cultural needs and provided staff with clear guidance on how best to meet these needs. This meant staff had up to date information about the residents needs and preferences. Care Homes for Older People Page 13 of 28 Evidence: Staff who completed a questionnaire indicated that they were given up to date information about the needs of the residents. One person wrote, The care plans are regularly updated and we have a handover at the start of the shift. The residents confirmed they were involved in the care planning process and had signed their plans to indicate their participation and agreement. One resident said, I read it every month and talk it over with the manager. This ensured the residents had an active role in the planning and delivery of their care. Written records seen on the residents files demonstrated that the care plans were reviewed each month and updated in line with changing needs. This meant the staff had access to up to date information about the residents health and well being at all times. Healthcare needs were considered during the assessment process and there was a designated section within the care plan, which provided information for staff on how to monitor and respond to specific medical conditions. There was written evidence within the personal care notes to indicate that the residents accessed NHS services and received specialist support as necessary, for instance the District Nursing Team. Charts were maintained to monitor the residents weight, to ensure any fluctuations were noted and acted upon. Risk assessments had been carried out as necessary, in respect to moving and handling, pressure sores, falls and nutrition. The risk assessments were supported by risk management strategies, which provided staff with guidance on how to manage and reduce any identified risks. This meant the staff were able to respond consistently and safely in to any identified risks. The residents spoken to felt the staff respected their rights to privacy and dignity and all made complimentary remarks about the staff, for instance one person said You only have to ask and they will help you all they can - nothing is too much trouble for them. The residents, who completed a questionnaire indicated that they received the care and support they needed. One person commented, The staff are always very helpful. The staff were observed to interact with the residents in a positive manner and they referred to the residents in their preferred form of address. During discussions, staff demonstrated an awareness of treating people with respect and considering their dignity when providing personal care. Policies and procedures were in place to cover all aspects of the management of medicines and were available for staff reference in the main policy and procedure file. The home operated a monitored dosage system of medication, which was dispensed Care Homes for Older People Page 14 of 28 Evidence: into blister packs by a local Pharmacist. Appropriate records were maintained in respect to the receipt, administration and disposal of medication. Since the last inspection, the registered manager had ensured that prescribed medication was available on the premises at all times. All staff designated to administer medication had received accredited training. Suitable arrangements were in place for the storage and administration of controlled drugs. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were able to exercise choice and control over their lives and were supported to maintain good contact with their family and friends. The residents were provided with a nutritious and varied diet. Evidence: The residents preferences in respect of social activities were recorded and considered as part of the assessment and care planning processes. A range of activities was planned and implemented by the manager and staff. These included exercise sessions, nail care, hairdressing, clothes parties, quizzes and sing-a-longs. The residents were encouraged and supported to participate in the activities as they wished. Residents spoken to during the inspection said they enjoyed participating in the various activities, one person said, We have lots of fun, theres always something to do. The residents were consulted on a daily basis about what activities they wished to pursue. Information about forthcoming activities was displayed in the hallway. On the day of inspection, the residents were observed to be reading newspapers, chatting to staff and having a hand massage. The residents were supported to continue with their chosen form of religious worship. Care Homes for Older People Page 16 of 28 Evidence: Representatives from local churches visited the home on a regular basis and an ecumenical service was held approximately once a month, for all those residents who wished to participate. The routines were flexible and were primarily designed to meet the needs of the residents. The residents spoken to said they had a choice in the times they got up and went to bed. One person said I can do as I wish, I like to follow my own routine in the morning. The staff were observed to seek the residents views throughout the inspection and the residents spoken to felt comfortable to comment on life in the home. The residents had the opportunity to develop and maintain important personal and family relationships. There were no restrictions placed on visiting times and residents were able to receive their guests in private, should they wish to do so. Refreshments were offered to visitors, to ensure they felt welcome in the home. Relatives spoken to during the inspection were satisfied with the quality of care. One person commented I am very happy with the service provided, everyone is looked after very well and the staff are so friendly and helpful. All the residents spoken to said they liked the food provided. There was a choice of food each meal time and residents were asked prior to each meal what choice they wished to make. The food was homemade and breakfast was served throughout the morning to suit the preferences of the residents, who wished to have a lie in. The menu was displayed in the hallway, so residents were aware of the forthcoming meal. Residents were asked their opinion of the food on an ongoing basis and they could make suggestions for future meals. The meal served on the day of inspection was plentiful and well presented. Residents were given sensitive and appropriate support to eat their meals. Drinks and snacks were served throughout the day and at other times on request. Jugs of juice and water were left around the lounges, to ensure that residents benefited from good hydration. Care Homes for Older People Page 17 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were able to express their views and had access to a clear complaints procedure. Policies and procedures were in place to respond effectively to any allegations or suspicions of abuse. Evidence: Arrangements were in place to ensure the registered manager and staff listened to and acted on the views and concerns of residents. This was achieved during daily conversation, one to one discussion and satisfaction questionnaires. The residents spoken to said they felt comfortable about expressing their views and were aware of whom to speak to in the event of a concern. Further to this, one resident wrote on a questionnaire, I could talk to the manager if I had any problems. The complaints procedure was included in the statement of purpose and service users guide and was also displayed in each bedroom. The residents had been issued a personal copy of the complaints procedure as part of the service users guide. The procedure contained the necessary information and included the relevant telephone numbers should a resident wish to raise a concern. According to information in the AQAA, the registered manager had not received any complaints during the last twelve months. An appropriate recording system was in place in the event of a complaint being made. Care Homes for Older People Page 18 of 28 Evidence: The policies and procedures for safeguarding vulnerable adults were available and provided guidance for staff should they suspect or witness any harmful practice. These issues were incorporated into the induction training and staff received specific tuition as part of their NVQ training. The staff also had access to a whistle blowing procedure. The procedures associated with the protection of vulnerable adults had been fully discussed at staff supervisions, to ensure staff were aware of how and where to direct any concerns. 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. Residents were provided with a clean, pleasant and well-maintained environment, which promoted their comfort and independence. Evidence: Brookdell is a mature detached property set in its own grounds in a quiet residential area of the village. The gardens are attractive, private and well maintained. Accommodation is provided is five single rooms and five double rooms. One double room has an ensuite facility. Privacy curtains are provided in double rooms to separate the personal space in the room and also around the washbasins. Communal space is provided in two lounges, both of which have a dining area. The hallway can also be used by residents as a quiet area to sit or entertain their visitors. Bathrooms and toilets are conveniently positioned around the home with the relevant aids and adaptations. A chair lift eased access to the first floor. The residents had free movement around the home and could choose where they wished to spend their time. An overall audit of the environment was carried out twice a year, to ensure all necessary repairs were carried out. Arrangements were in place for general maintenance and general repairs. This meant that routine problems with the building were promptly rectified. Care Homes for Older People Page 20 of 28 Evidence: It was evident from a partial tour of the building that the residents had personalised their rooms with their own belongings and decoration was a good standard throughout. The residents said they liked their bedrooms. One person said, I have a lovely room, Im very comfortable in it. Since the last inspection, various improvements had been made to the premises. These included repairs to the kitchen units and redecoration of one bedroom. New wardrobes had also been purchased for one of the bedrooms. The registered manager reported that a new garden room was due to be built within the next three months. This room was expected to provide additional seating for the residents and a view of the garden. The home was clean and odour free at the time of the inspection. The residents and relatives spoken to said that a good level of hygiene was maintained at all times. All the residents who completed a questionnaire indicated that the home was always fresh and clean. 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. The residents benefited from experienced, competent and well-trained staff. Evidence: The registered manager maintained a master rota and explained the staff carried out the same duties every week. In the event of an absence, alternative staffing arrangements were recorded in the diary. The registered manager confirmed that two members of staff plus the manager were on duty 8.00 am to 5.00 pm, two members of staff were on duty from 5.00 pm to 10.00 pm and one person was on waking watch, with one person sleeping in an adjacent property. All staff who provided personal care were aged over 18 and all staff left in charge of the building were aged over 21. Many of the staff had worked at the home for several years and had a good knowledge of the needs of the residents. A recruitment and selection procedure was available and a checklist was used to track documentation required for the recruitment of new staff. The files of three members of staff were looked at in detail. It was evident that all the applicants had completed an application form, provided a full working history and had attended the home for an interview. CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks had been obtained prior to the applicants commencing work in the home. However, it was noted that only one reference had been received for one person Care Homes for Older People Page 22 of 28 Evidence: before they commenced work in the home. Further to this, the registered manager updated the recruitment procedure and checklist, to ensure two references were in place prior to future staff having access to the residents. Arrangements were in place for all new employees to undertake induction training. Since the last inspection, the induction training had been reviewed to include the Skills for Care standards. The latter provided underpinning knowledge for NVQ level 2. According to information supplied by the registered manager six care staff had achieved NVQ level 2, which equated to 47 of the overall staff team. In addition six members of staff were working towards this qualification. As such the manager was confident that over 50 of the staff would achieve NVQ level 2 in the near future. All the staff who completed a questionnaire confirmed they received training relevant to their role and all commented that they were well supported by the management team with any training needs. Staff attended both internal and external training courses and had at least three paid days training a year. It was noted staff discussed their individual training needs during their supervision sessions and there was an overall staff training plan. This meant the manager could readily identify future training needs for individual staff and for the staff team as a whole. Care Homes for Older People Page 23 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management and administration practices were effective in ensuring the home was run in the best interests of the residents. Evidence: The registered manager had overall responsibility for the management of the home and had achieved the Registered Managers Award and NVQ level 4 in Management. Since the last inspection the manager had completed NVQ level4 in Care. The manager had also attended liaison meetings with Lancashire County Councils Contracts Department and undertaken various short courses, including infection control to refresh her knowledge and skills. The management approach was consultative and there were established ways of working to consult the staff and residents on an ongoing basis. Relationships within the home were positive and staff spoke to and about the residents with respect. Further to this, a member of staff wrote in a questionnaire, The staff are nice and they look after Care Homes for Older People Page 24 of 28 Evidence: the ladys very well and another member of staff commented, The service always makes sure that the residents are cared for in all aspects. There was a programme in place for staff supervision and the topics discussed during supervision were recorded on a suitable format. Staff received formal supervision six times a year and had an annual appraisal of their work performance once a year. In addition to supervision, staff were given the opportunity to attend regular informal staff meetings and handovers. This meant that the staff were able to share experiences and discuss future developments. The service was reaccredited with an Investors in People Award in November 2006 and was on the Local Authorities preferred provider list. Satisfaction questionnaires had been distributed to residents and their residents in March 2008. The results of the questionnaires had been collated and displayed in the home to provide the residents with the outcome of the survey. Since the last inspection, the registered manager had produced an action plan and business plan, both of which set out the aims and objectives for the forthcoming year based on the results of the quality monitoring processes. This document linked with the AQAA questionnaire submitted to the Commission. All sections of the AQAA were completed and the information provided gave a clear picture of the current situation within the service and the planned areas for development. Appropriate arrangements were in place for handling money, which had been deposited with the home by or on behalf of a resident. A random check of the records and monies deposited on the premises was found to be correct. This meant the residents financial affairs were safeguarded. There was a set of health and safety policies and procedures, which included the safe storage of hazardous substances and infection control. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Documentation seen during the inspection and information supplied in the AQAA indicated the electrical, gas and fire systems were serviced at regular intervals. The fire log demonstrated that the staff had received instructions about the fire procedures during their induction. However, it was noted there had not been a fire drill for sometime. Risk assessments had been completed in respect to safe working practice topics, including fire safety. Arrangements were in place to record accidents and incidents in the home and the Commission had been notified as appropriate of any significant event in 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 1 29 19 The revised recruitment procedure must be fully implemented. This is to ensure that two references are obtained for all new staff commencing work in the home. 31/10/2008 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 37 The registered manager should seek advice from the Fire and Rescue Service about the frequency of fire drills. This is to ensure that the staff and residents have the opportunity to practice what actions to take in the event of a fire. Care Homes for Older People Page 27 of 28 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 © (2008) 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. 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