Inspection on 31/07/08 for Cossins House Care Home

This inspection was carried out on 31st July 2008.

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

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

Other inspections for this house

Cossins House Care Home 18/07/07

Cossins House Care Home 20/11/06

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Cossins House Care Home 1 Downside Road Downside Cobham Surrey KT11 3LZ     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: Patricia Collins     Date: 3 1 0 7 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: Cossins House Care Home 1 Downside Road Downside Cobham Surrey KT11 3LZ 01932 862038 01932 863497 cossins.house@fshc.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Grandcross Limited(wholly owned subsidiary of Four Seasons Health Care Ltd) Mrs Carol Patricia Kirby care home 24 Name of registered manager (if applicable): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: 0 Over 65 24 Date of last inspection Brief description of the care home Cossins House is a care home providing personal care for up to 24 older people. The home is operated by Four Seasons Health Care which is a national care provider. The home is set in four acres of landscaped gardens overlooking the countryside. It is situated in the village of Cobham, which provides good transport links, shopping facilities and a local church. Car parking is provided at the front and side of the home. The accommodation comprises of 21 en-suite bedrooms arranged on the ground and first floor, some of which are adequately spacious for shared occupancy. There is a passenger lift to provide access to the first floor. Communal facilities include spacious Care Homes for Older People Page 4 of 28 lounges and a separate dining room. In addition, three bungalows are available within the grounds offering a greater level of independence for people using services. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 stars. This means that the people using this service experience good quality outcomes. Fee levels range between £500 and £800 per week. The date of the last key inspection was 18th July 2007. The unannounced inspection visit formed part of the key inspection process using the ‘Inspecting for Better Lives’ (IBL) methodology. It took place over eight hours and was undertaken by one regulation inspector. The report will say what ‘we’ found as it is written on behalf of the Commission for Social Care Inspection (CSCI). Care Homes for Older People Page 6 of 28 The home manager represented the organisation and was present throughout the visit. Judgements about how well the home meets the national minimum standards for older people have been formed on the basis of the cumulative assessment, knowledge and experience of the home since its last key inspection. The Annual Quality Assurance Assessment (AQAA), which is a self-assessment and dataset completed annually by management, also informed the inspection outcomes. We have taken account of all information obtained through discussions with people using the homes services, the manager, deputy manager, staff on duty and two visitors. A tour of the premises and garden took place during which we inspected all communal areas, the kitchen, laundry and some bedrooms. Records, policies and procedures were sampled and care practice, arrangements at lunch time and a group activity were observed. We wish to thank all who contributed information to the inspection process. Also people using the home’s services and staff for their time, hospitality and assistance throughout the inspection visit. What the care home does well: What has improved since the last inspection? All requirements from the last inspection had been met. Staff had received safeguarding adults refresher training and other statutory training. The staff rota is now accurately maintained and staff recruitment procedures had been improved. A risk assessment had been carried out for the person using services discussed at the time of the last inspection. This person has since relocated to a bedroom more suited to her needs. The homes management has been strengthened through the recent promotion of a senior carer to the post of deputy manager. A new activities organiser took up post at the beginning of the year and the the social activities programme has been developed and extended. This affords a range of recreational activities that meet the expectations of people using services. The activities programme also incorporates opportunity to engage in community activities and social events at the home. A redecoration and refurbishment programme is ongoing. A vacant cottage was being upgraded at the time of the visit and there had been a number of improvements to the Care Homes for Older People Page 8 of 28 environment. These included replacement of windows and floor coverings and new kitchen equipment and appliances. 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. 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 using services and their representatives receive the information they need to enable an informed choice about the homes suitability. There is opportunity to move in to the home on a trial basis to assess the quality of services and facilities. Admission decisions are based on the findings of comprehensive needs assessments to be sure that needs can be met. Evidence: The homes management understands the importance of having sufficient information when choosing a care home. A comprehensive statement of purpose has been produced stating who the home is for. This is available on request to people considering using the homes services. An information pack has been professionally produced which includes a statement setting out the homes aims and objectives and Care Homes for Older People Page 11 of 28 philosophy of care. It also includes a service users guide describing how the home operates. This is specific to the needs of the people for whom the home is intended. This information is displayed in the welcoming entrance hall together with the homes brochure, a copy of the latest inspection report, the complaint procedure and a leaflet about local safeguarding adults procedures. The home has a clear admission criteria and the admission procedure are underpinned by Four Seasons Health Care equal opportunities policy. Pre-admission assessments are carried out by suitably skilled managers. The process is inclusive, focusing on achieving positive outcomes for the individual. This ensures the homes facilities, staffing and specialist services meet individual needs and cultural and diversity needs are identified. The service is efficient in obtaining a summary of any assessment undertaken by care management or other agencies. Discussion took place with a person staying at the home who was on a four week trial placement. The purpose of this was to allow her to assess whether the home was right for her before making a decision about giving up her own home. She told us that staff had spent time with her responding to any queries she had about life at the home. Though significant time and effort was evidently spent on planning admissions to make the experience personal and well managed, comments received from a relative highlighted where improvements in practice could be made. In particular, the importance of ensuring that all staff are briefed when a new person is expected for admission to ensure an appropriate welcome on arrival. The manager agreed to review this area of practice. The home does not provide intermediate care. 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. Health and personal care delivery is based on individual needs assessments and set out in a plan of care. The principles of respect, dignity and privacy are put into practice. Medication policies and procedures ensure the health and welfare of people using services. Evidence: Discussions with people using services confirmed the approach to assessment and care planning is inclusive, involving them so far as they wish to be and within individual levels of capacity. Care plans were in sufficient detail and based on comprehensive needs assessments. Risk assessments had been carried out and risks management plans were in place. Wherever practicable people using services or their representatives signed their care plans, signifying their involvement in the process. The approach to care planning and meeting individual personal and health care needs Care Homes for Older People Page 13 of 28 is person - centred and flexible. Care and support is based upon the rights of dignity, equality, fairness, autonomy and respect. Personal and health care needs, including specialist health, nursing and dietary requirements were all clearly recorded in the care plans sampled. Staff practice was observed to respect the privacy of people using services in the delivery of care; also by staff knocking and waiting for an invitation before entering bedrooms. Without exception feedback was positive from people using services about the care they received. One person stated that she used to live with her husband in one of the cottages in the grounds up until his death. It had been her choice to move into the main house some time later. She stated that when she lived in the cottage staff came in to see her most days. She commented, The manager is excellent and we cant fault the staff, they are all kind and caring. The new activities person is excellent. If I feel anxious about anything I can go to away with peace of mind after talking with her. Another person staying at the home for respite care said she had not stayed at the home previously. She was only there whilst her family were on holiday and had looked round this home and others before deciding to stay at Cossins House. When asked the reason for her choice she said, The atmosphere is so friendly and calm, the building is lovely and the grounds are immaculate. Its just like your own home, what more could we ask for? The home has an efficient medication policy supported by procedures, practice and audits. The deputy manager has relevant knowledge and experience relating to her delegated responsibility for the management of the homes medication. A monitored dosage system is used and supplied by a local pharmacy. The medication room is airconditioned and a medication trolley used for administering medication. Staff are diligent in recording the temperature of the medication cold storage facility. Medication records were sampled and found to be complete, containing required entries and signed by appropriate staff. Staff who administer medication had received relevant training. Based on the observations made it was concluded that the home is compliant with statutory requirements for the storage, recording, administration and disposal of drugs. Suitable controlled drugs storage and related systems were also in place, though no controlled drugs currently prescribed. 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 the homes services can make choices about their lifestyles. They have opportunity to engage in a social activities programme, to access their local community and maintain contact with family and friends. A balanced and varied diet is offered. Evidence: A full time chef is employed who prepares home cooked food using fresh and frozen produce. Three full meals are offered daily with snacks and hot and cold drinks at regular intervals. A dietitian was consulted some time ago and her advice had been incorporated into menu planning to ensure nutritionally balanced meals. Special dietary needs can be accommodated to meet medical, religious and cultural requirements. A corporate menu is followed with some local variations based on the suggestions and preferences of people using services. A four weekly rotating menu is in operation which includes meat, fish, pasta, fresh vegetables and fruit. There is a choice of meals and the chef consults all people using services each morning to ask Care Homes for Older People Page 15 of 28 what they would like for lunch. A record is maintained of alternative meals served and a list of breakfast preferences is followed. A quality monitoring system is in place to ensure satisfaction with meals. The chef ensures her attendance at residents meetings. These afford opportunity for people using services to express their views about the food and offer suggestions for change. Relatives and friends of people using services are welcome to dine with them for a small charge and prior notice given to the chef. The chef and kitchen assistant were observed working in the kitchen. This was clean and hygienic at the time of the visit and adequately equipped. The cooker had been replaced since the last inspection and a new fryer and kitchen utensils had been purchased. The dining room is spacious and dining tables nicely laid and the menu was prominently displayed. Lunch was observed and the meals were nicely presented and appeared appetising. Care staff carried the plated meals to the tables and discreetly offered assistance where needed. The atmosphere in the dining room was congenial and unhurried. People using services confirmed they make everyday choices about their lifestyles. Discussion took place with the activities organiser who took up post in February this year. She works three days a week, usually on Tuesdays, Wednesdays and Thursdays though the days and times can be flexible.The social activities programme has been developed based on the suggestions and interests of people using services. It was displayed on a notice board in the lounge and a personal copy also distributed each week to each person. Group and one to one activities are provided. Examples of these include film shows, mini-bus outings, board games, discussions and sherry mornings. On the day of the inspection five people using services participated in a gentle exercise activity to music which they were observed to enjoy. The activities organiser and staff encourage people using services to socialise whilst respecting the wishes of those who prefer not to. There is an activities budget which funds social events, entertainers and mini bus excursions. A group of people using services had enjoyed a trip to Richmond park the day before the inspection. All activities are risk assessed and care staff accompany the activities organiser on group outings. A successful open day was arranged at the home in May and family and friends invited. Photographs of this event were on display. Discussions with individual people using services confirmed they had enjoyed the experience and had not found it intrusive to their privacy. A hairdresser visits regularly and newspapers and magazines can be ordered and delivered daily. The home has a television lounge and sitting room with piano. The manager confirmed a commitment to trying to meet the religious and spiritual needs of people using services. These are explored as part of the pre-admission assessment Care Homes for Older People Page 16 of 28 process. A Church of England vicar was stated to regularly visit. Visitors are encouraged and there are no restrictions on visiting times. A number of visitors were observed in the home during the course of the day. A number of people using services had telephones in their bedrooms at their own cost, enabling them to maintain contact with friends and family. The extensive, immaculately maintained grounds provide a pleasant outlook with sitting areas, facilities for a game of bowls and paths to enjoy a pleasant stroll. There is also a furnished patio. Care Homes for Older People Page 17 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the homes services are able to express any concerns and have access to a robust, effective complaint procedure. They are protected from abuse and staff respect their rights. Evidence: We have not received any complaints about this home since the last inspection. The homes complaints procedure is displayed in the entrance hall and is stated in the service users guide. The corporate complaint procedure is followed which includes timescales for responding to complainants; also contact details for the Commission for Social Care Inspection. New complaint forms had been introduced since the last inspection. There had been one complaint in the past twelve months about fees which was sent to and dealt with by the organisations head office. Discussions with people using services confirmed they were aware of who to speak to about any concerns or complaints. The information they provided confirmed that management promotes a culture that enables people using services to express their views and welcomes suggestions. The home follows the organisations safeguarding adults procedures. There is also a copy of the local safeguarding adults protocol. The staff team including the manager Care Homes for Older People Page 18 of 28 had undertaken safeguarding adults refresher training since the last inspection. Staff have also received equalities and diversity awareness training. Managers were clear of when an incident must be referred to the Local Authority as part of the local safeguarding adults procedure. Staff consulted were aware of indicators of abuse and stated they would report any allegations or suspicions of abuse to the manager. They were also aware of the whistle blowing policy. Since the last inspection there has not been any safeguarding adults referrals involving people using services. Care Homes for Older People Page 19 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the homes services live in a safe, hygienic, well maintained and comfortable environment that encourages independence. Evidence: The exterior of the home was tidy and the extensive private grounds were well maintained. The home has 21 en-suite bedrooms for single occupancy though several are very spacious and could comfortably be occupied by sharing companions. There are also three cottages in the grounds providing accommodation on one level offering a greater level of independence. A tour of the premises was undertaken in which all communal areas were viewed and bedrooms sampled. The three cottages were also visited. Bedroom accommodation in the main building is arranged on two floors accessible by a passenger lift that has recently been upgraded. The bedrooms viewed were nicely decorated and comfortably furnished. They were personalised with items of furniture and possessions belonging to people using services. Call bells were within easy reach of the people visited in their rooms and were seen functioning. A person who is visually impaired had been supplied with a pendant type call bell for her convenience and safety. Care Homes for Older People Page 20 of 28 Sitting rooms and the dining room were tastefully decorated and furnished in keeping with the traditional style of the premises. All communal areas were accessible to people using services and grab rails provided, to maintain independence. Bathrooms and toilets were clean and hygienic and had liquid soap and paper hand towels. A bath aid was available for assisting people in and out of the bath and the homes equipment includes a hoist. A redecoration and refurbishment programme was ongoing. A vacant cottage was being upgraded and windows had been replaced in bedrooms 4 and 17. Work had also been carried out to the entrance of two cottages and a third had a new door and radiator covers. New non-slip flooring had been laid in three en suite rooms and the floor covering replaced in a bedroom corridor. Future plans include fitting non-slip flooring in a further two en-suite rooms, building a conservatory and tenders had gone out for plans to refurbish a bathroom. The manager said she had consulted the estates manager about proposals to improve the safety of the access to a bedroom. The manager confirmed that occupants of this room now have robust risk assessments carried out to ensure their safety. This room was in use by someone receiving respite care. Currently the home does not have housekeeping staff since the retirement of both housekeepers earlier this year. The manager confirmed difficulties in recruiting to these vacancies. Cleaning routines were being covered by care staff and the cook who worked additional hours designated specifically for cleaning. Though the home was clean and odour well managed at the time of the visit, information received from a relative identified shortfalls and dissatisfaction with cleaning standards. We also observed two full waste bins in a bedroom and it was evident these had not been emptied for some days from the content. Since the inspection visit the manager has confirmed agency cleaning staff are being used to ensure a good standard of cleanliness and hygiene at all times. 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. People using services are protected by robust staff recruitment practice and their needs are met by the numbers and skill mix of staff.There is a training and development programme for staff to gain the required skills and competencies. Evidence: Shortfalls in staff recruitment and the rota identified at the time of the last inspection had been addressed. The homes staffing structure is based around the delivery of outcomes for people using services. The rota demonstrated consistent staffing levels of three care staff including the deputy manager, throughout the waking day. A chef, kitchen assistant and two waking night staff are employed, also a part-time gardener/handy-person and part-time activities organiser. The manager works supernumerary to staffing levels. A new administrator and a second part-time garden were being recruited. The manager had been unable to recruit to vacant housekeeping posts since the retirement of both housekeepers earlier in the year. The kitchen assistant had until recently worked additional hours to cover cleaning duties. The cook and care staff were now working overtime to undertake cleaning tasks. Comment has been made earlier in this report Care Homes for Older People Page 22 of 28 report on shortfalls in cleaning standards and the proposed remedial action by management. We looked at staff recruitment procedures and their induction and training and sampled staff records.The staff recruitment procedure is underpinned by equality and diversity principles and has the needs of people using services at its core. Recruitment processes include using new documentation and ensure robust vetting procedures are followed for the protection of people using services. A bank worker recruited earlier in the year had not supplied a full employment history and the manager took immediate remedial action during the inspection visit when drawn to her attention. On reviewing the recruitment records of two prospective employees it was noted that full employment details had been sought. The records viewed evidenced that full statutory staff vetting procedures were followed. We examined the staff training plan and training records evidenced recent training on abuse, fire safety, medication and stoma care. The kitchen assistant had received infection control and safer food for all training. We looked at the induction records for a new bank worker which were incomplete. The manager is aware of the time-scale for completion and confirmed this would receive urgent attention. It was noted this worker had only worked a few shifts since her appointment. The homes annual quality assurance assessment informed us that fourteen care staff are employed, including bank staff, of which nine have an NVQ Level 2 qualification in care or equivalent. The home therefore meets the national minimum standard of 50 of staff attaining this qualification. Staff were observed to be professional in their appearance and conduct . Those consulted during the course of the visit considered the home to be well managed and staffing levels to be adequate. Individuals stated they enjoyed working at the home and described good teamwork. Without exception the feedback from people using services about staff was positive. The atmosphere between staff and people using services was warm and friendly. Care Homes for Older People Page 23 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is effectively managed and run in the best interest of people using services. The management and administration of the service is based on openness and respect and effective quality assurance systems are in place. Evidence: The manager is registered and informed us that she has over thirty years experience of caring for older people. The annual quality assurance assessment states she is suitably qualified. These include NVQ Level 3 in care, NVQ Level 4 in management, the Registered Managers Award and NVQ Assessor and Internal Verifier. Care Homes for Older People Page 24 of 28 The promotion of a senior carer to the post of deputy manager is a recent development. The manager was present throughout the inspection and the deputy manager kindly came in for part of the visit which was on her day off. Observations confirmed both had clearly defined roles and responsibilities. Clear lines of accountability were evidenced within the home and with external management. The manager confirmed receiving good support from her line manager who visits regularly. Discussions with the manager and deputy manager demonstrated a clear vision for the home. This is based on the organisations values, corporate priorities and objectives for achieving quality outcomes for people using services. The annual quality review assessment (AQAA) completed by the manager contained clear, relevant information supported by a wide range of evidence. It let us know about changes that have been made and where management still need to make improvements and how these will be achieved. All requirements from the last inspection had been met. The manager fully recognises the importance of the AQAA and it has been used to inform corporate quality assurance systems. These provide continuous self-monitoring and involve consulting people using services and their representatives. Records were viewed of visits carried out by senior management on behalf of the responsible individual. These visits were undertaken monthly and in accordance with statutory requirements. Health and safety and fire safety risk assessments were sampled. Also the gas certificate viewed and records verifying regular servicing of fire detection and fire fighting appliances. Health and safety audits were carried out by management and action had been taken to minimise risks where identified. All radiators were covered for the protection of people using services; also hot water temperatures controlled at a safe level and monitored, in areas accessible to people using services. The estates manager has been consulted and is considering ways for improving the safety of access to a bedroom. Other areas of discussion included the need to provide safety locks on bedroom doors if people using services request a key to their rooms. Observations concluded that the homes management ensures as far as reasonably practicable the health, safety and welfare of people using services and staff. We were informed by the manager that the home has no involvement with the personal finances of people using services. Care Homes for Older People Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 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. Care Homes for Older People Page 28 of 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!