Inspection on 21/10/08 for Dungate Manor Care 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Dungate Manor Care Home 30/10/07

Dungate Manor Care Home 12/05/06

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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: Dungate Manor Care Home Dungate Manor Flanchford Road Reigate Heath Surrey RH2 8QT     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: Deborah Sullivan     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 32 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 32 Information about the care home Name of care home: Address: Dungate Manor Care Home Flanchford Road Dungate Manor Reigate Heath Surrey RH2 8QT 01737244149 Telephone number: Fax number: Email address: Provider web address: dungatemanor@schealthcare.co.uk Name of registered provider(s): Name of registered manager (if applicable) Ashbourne (Eton) Limited Type of registration: Number of places registered: care home 45 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability sensory impairment Additional conditions: Date of last inspection Brief description of the care home Dungate Manor is a care home for up to forty-five people. The home is situated in a peaceful, semi rural location, a few miles outside the town of Reigate and is next door to a golf course. Car parking is available to the front of the home. The home is a large Edwardian building set in extensive gardens to the front and rear. The building has been extended in the past to provide additional accommodation, and now offers a Care Homes for Older People Page 4 of 32 Over 65 4 4 45 5 5 0 0 0 0 0 Brief description of the care home selection of bedrooms, the majority for single occupation and some with en-suite facilities. A small number of shared bedrooms are also available. The accommodation is arranged over three floors served by a lift. A choice of communal rooms, including a large lounge, a conservatory and a spacious dining room are provided on the ground floor. Care Homes for Older People Page 5 of 32 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 previous key inspection of Dungate Manor was undertaken on 30th October 2007. This unannounced key inspection took place over seven hours,during the visit time was spent with residents,the manager,the operations manager,the administrator, head cook and care staff.A tour of the building took place and a range of records and documentation were read including care plans,medication records,staff files and training information. Information provided in the AQAA (Annual Quality Assurance Assessment)document completed by the manager has also been used as part of the evidence for this inspection, as have survey forms completed by a small number of residents and staff. Care Homes for Older People Page 6 of 32 Throughout the day residents and staff spoken with were helpful in providing information to assist the inspection process. The fees for the service range from six hundred and forty to seven hundred and ninety pounds per week. What the care home does well: What has improved since the last inspection? The home had gone through a period of instability with the lack of a permanent manager.Despite this action had been taken to meet the requirements made at the last inspection. A new manager has now been appointed who has brought about some positive changes to the quality of the service. The statement of purpose has been revised and contains up to date information about the service provided. Improvements have been made to the information recorded on care plans and they are becoming more person centred. In recent months staff awareness of their responsibilities to make sure that residents are protected from abuse have been improved upon. There is now a dedicated medication room that is well equipped and secure. There have been some environmental improvements such as refurbishment and repainting in some areas of the home,the drive has been partially resurfaced,there is a new boiler and a waiting room for hairdressing has been created. New care and domestic staff have been recruited and recruitment procedures are improved so that past work histories are fully recorded. Care Homes for Older People Page 8 of 32 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 32 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 32 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. Potential residents and their representatives have access to information about the home and are welcome to visit before they decide to move into the home. Assessments take place prior to admission and each resident is provided with a written contract. Evidence: The home has a statement of purpose and service users guide, both contain up to date information about the service and are well presented,there are also colour brochures and leaflets available. Prospective residents and their representatives are welcome to spend time at the home to get a feel of what it is like to live there and if appropriate trial periods are offered. At the time of the inspection the home was not full.Respite is available,one person had been admitted that week for a period of respite and two more were expected within a few days.Respite can lead to full time admission. Each Care Homes for Older People Page 11 of 32 Evidence: prospective resident is fully assessed by the manager before a place is offered and senior care staff are now also involved in the assessment process.Assessment information is documented on care plans. The majority of residents were privately funded and some were funded by their local authorities.Contracts are provided for all residents either with the local authority or personally.Some contracts for private residents were seen including that of a resident who had transferred from private to social services funding,all were signed and included information on the fee payable. Care Homes for Older People Page 12 of 32 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. Each resident has a care plan that reflects their health,personal and social care needs and preferences. Care plans are of a good standard, work to make sure they are all signed by the resident or their representative must be completed. Service users are treated respectfully by staff and their privacy is respected. Medication procedures and storage have been improved and all staff who administer medication receive medication training. Evidence: Each resident has a care plan that gives clear information about their individual needs and preferences.Three care plans were read,they were all well maintained and included Care Homes for Older People Page 13 of 32 Evidence: good information about how each individuals needs were to be met.Risk assessments were in place relevant to the individual such as in respect of the use of hoists or a wheelchair, and one person had a risk assessment in place for smoking.There was evidence that the plans were being reviewed, of nutritional and weight monitoring and thorough daily recording.Some information on personal histories was in place and the manager said that this is being developed.Where residents had expressed a preference for a male or female carer to attend to their personal care it was recorded.The needs of residents are diverse with some being more independent than others.Spiritual preferences are recorded. During the visit care staff observed assisted people appropriately and according to their needs,a carer spoken with said that they felt they knew each persons individual needs in detail and they were key worker to a number of residents. A resident stated on a survey form that their care and support was of an unexpectedly high level. Health needs and input from health care professionals are well documented and there was detailed information about a service user who had recently been discharged from hospital and it was clear the hospital had not communicated properly about this.Work is taking place to strengthen links between the home and health colleagues and residents are supported to maintain contact with health professionals such as chiropodists,dentists,GPs and district nurses.The manager discussed recent work that had taken place to refer a resident for a new wheelchair that they would be able to use more safely than their current one, although it was frustrating that it would take some months to arrive.The same resident was to have new dentures so that they would be able to eat and drink more easily.In the interim there were procedures and assessments in place to ensure the resident was eating and drinking enough. Another resident who was at risk of skin breakdown was carefully monitored and had a profiling bed. The last inspection identified that care plans had not been signed by residents or their representatives,this has started to be addressed and care plans for new residents or those in for respite are signed with others being signed on review.Agreements for the use of bed rails are also now in place as was required. The home has very recently started using a dedicated room for the storage of medication and medication related information and documents.Medication and written information used to be kept in various locations but a spacious,well equipped and well ordered room is now in use.New cupboards and cabinets for storage as well as work surfaces had been fitted and there is comfortable seating and room for district nurses to attend to residents if they do not wish to be treated in their bedrooms.The room was rather overheated,the manager took action to rectify this during the visit. Medication in use is stored in a new trolley that is tethered when not in use.MAR Care Homes for Older People Page 14 of 32 Evidence: sheets examined were correctly completed. Only staff trained to administer medication undertake this role.A medication training session provided by Boots was taking place during the inspection for some existing and new staff.New storage is also being used for incontinence pads so that they are kept more discreetly and the dignity of residents is better maintained. Care Homes for Older People Page 15 of 32 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 are offered activities and can pursue their own interests at the home.There is a need for the activity programme to be expanded. Visits and contact from friends and relatives are welcomed. Meals are healthy,nutritious, well cooked and presented and choice is available. The home must take care to make sure correct information on meals is displayed. Evidence: The home offers residents a variety of activities,an activities coordinator is employed part time and there is an activities programme on display.Activities include chair exercises,painting,music,visits by an entertainer and films.A PAT dog arrived during the afternoon of the visit.The home has a resident cat and an attractive tropical fish tank,one resident said they liked the fish and thought they had grown, they also especially liked the music sessions.The coordinator was not on duty and a staff member was helping a resident with a crossword,another resident was reading the paper,others were watching TV,spending time in their rooms or in the various lounge Care Homes for Older People Page 16 of 32 Evidence: areas.Some survey forms returned by residents and staff referred to the need for outings to be offered one resident said that activities like minibus trips would be welcome, and a staff member stated-There is need for more and different activities.Another resident said that -Staff work hard on the activities programme.The manager said that there he has secured the use of a minibus for one day a week so that trips out can be started and various social events are to be planned.A notice was on display about a bonfire night party and a resident had written a pantomime that was to be put on within coming months. One resident regularly goes out independently to a local pub. Holy Communion is held at the home regularly and residents are supported to practice their religious beliefs. The hairdresser who visits regularly was present and was popular,there is a dedicated hairdressing room and a room on the lower floor that was a bedroom has been converted into a comfortable waiting area for hairdressing,the manager hopes to improve it further. Residents are supported to maintain contact with friends and relatives,relatives were visiting during the inspection and were comfortable in referring any queries to the manager.There is ample room for visits to take place in private if residents choose not to receive visitors in their bedrooms. Meals are served in the spacious dining room,tables were attractively laid with linen tablecloths and serviettes and there were condiments on them.There are two lunch sittings,the earlier is for residents who need more support to eat their meal.Four residents were at the early sitting being assisted by a carer each.Support was given sensitively and the meal was unhurried.One resident who chose not to eat the first course was offered a sandwich and accepted it,when they chose not to eat the sandwich pudding was offered and accepted. The lunchtime meal was freshly cooked and looked appetising.The weekly and daily menus are on display but the weekly one was hidden by a flower arrangement and in very small writing.The daily one is in larger writing but still was not accessible for all residents.Both menus did not reflect the meal that was actually served.The head cook explained that the meal had changed due to the need to use up fresh ingredients and provide a favourite main course.A chart was seen that records service users daily choices and did have the correct meal on it, but the home must make sure the right information is on display and follow through the managers stated intention to provide more accessible information on meals. The head cook has worked at the home for a long time and takes care to make sure that meals are nutritionally balanced and healthy.They are aware of preferences and can cater for special diets such as diabetic and soft diets currently.New winter menus were soon to be written. Fresh cakes are baked daily and the head cook said birthday cakes are made for residents and staff birthdays. Care Homes for Older People Page 17 of 32 Evidence: . Care Homes for Older People Page 18 of 32 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. The home has a clear complaints procedure and residents and others can feel confident that any concerns or complaints would be taken seriously and addressed. Staff awareness of their responsibilities in respect of safeguarding residents has been improved and staff are equipped with the knowledge to recognise abuse and report it. Evidence: The home has a complaints procedure that is displayed in the reception area,there is also a suggestions box and suggestions forms for people to use.The equality and diversity statement is also displayed.Neither the home or the Commission had received any formal complaints about the service since the last inspection.Service users who returned survey forms said that they knew who to speak to about any concerns. There are safeguarding vulnerable adults procedures in place and staff awareness of their responsibilities to safeguard service users has been given priority following a safeguarding alert in the summer regarding one resident that led onto concerns being raised about four others.The safeguarding matter is now closed and there have been no further alerts.It had highlighted that there had been some breakdown in communication between the home and health professionals,the operations manager Care Homes for Older People Page 19 of 32 Evidence: put an action plan into place to address the issues and the home is working hard to improve relationships with outside professionals and promote awareness of abuse.A staff member has been appointed as the homes Action on Elder Abuse Champion and staff receive POVA training with updates.Two members of staff spoken with confirmed they had had the training and a carer spoken with felt confident that they would know what to do if they suspected abuse.Staff recruitment procedures are robust and the necessary vetting of staff protects residents. The home does not manage any residents personal monies and procedures are in place for invoicing for services such as hairdressing. The last inspection highlighted a need for inventories of personal possessions to be completed when residents move into the home,these are now being done. Care Homes for Older People Page 20 of 32 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 live in a clean,comfortable and homely environment. Upgrading in a number of shared areas and bedrooms is needed to keep the environment at an acceptable standard. Evidence: The home is a converted mansion that has been attractively refurbished and furnished in a homely way.As it a sizeable older building a good deal of ongoing maintenance is needed,the organisation and manager are aware of work that needs to be done to improve and maintain the building to a good standard and some work had already been requested,had taken place or was due to start. General upgrading of shared areas and some bedrooms was needed in terms of repainting,replacing or repainting window frames and sills, upgrading some bath/shower rooms,improving the garden and making more parts of it accessible, and replacing double glazing in the dining room as it is retaining condensation. Areas of the skirting boards throughout the home are chipped and need repainting and some furnishings in bedrooms and other areas need replacing. Whilst there is a substantial amount of work to be done the home was presentable in most areas and there was a good standard of cleanliness,one bathroom had an odour as the bin needed emptying.The manager had highlighted the need to Care Homes for Older People Page 21 of 32 Evidence: increase the number of cleaning staff and a service user stated on a survey that cleaning needed augmenting.The organisation had addressed this and a second cleaner was starting the day after the inspection. There are several areas for residents to access,there is a pleasant and spacious sitting area off the entrance way,a large well furnished lounge and a conservatory with garden access.The dining room is also spacious and there is a small library room.The TV was only on in the main lounge although there is one in each room. There are handrails throughout shared areas and specialist equipment is available for personal use where required such as wheelchairs or profiling beds. Some bedrooms seen were vacant and some were occupied.Two bedrooms in the basement were no longer being used as such, one had been temporarily converted to the hairdressing waiting area.Occupied bedrooms seen were all personalised with ornaments,pictures,photos and personal furniture, although some redecoration was needed they were all attractive, and due to the nature of the building, a variety of shapes and sizes.Most have pleasant views of the surrounding countryside and golf course and some are en suite.A resident said that -Im very happy with it here,Im very fond of my room. The upstairs corridor had been fully repainted and the carpet cleaned. There is a choice of bath or shower rooms,both first floor bathrooms contained hand soap and plastic jugs that should not have been left out as they could pose a risk of cross infection and in the first floor toilet wooden pipework casing and the flooring needed replacing.The bath in the second floor bathroom had a damaged panel,the manager said a replacement was on order. Throughout the home there are a number of unnecessary signs mainly stating that at various hand washing areas the water is very hot,which it was not, water tested was at an acceptable temperature.These notices need to be removed as they detract from the homely atmosphere. The laundry is well equipped and tidy,there is a new boiler. The overall impression is that the home is a clean and comfortable place to live but the identification of areas for improvement may have gone unnoticed or unattended to due to the lack of a permanent manager at the home for some time.This is now improving and some work has already been completed,is underway or costings have been prepared. Care Homes for Older People Page 22 of 32 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. Residents are supported by staff group who are confident and competent and recruitment procedures protect service users. Staff are well trained in core and service specific topics,more care staff must gain an NVQ in care qualification. Evidence: The home had enough staff on duty to meet the needs of residents,the home was not full and the manager said that should more service users move in staffing would increase.A carer spoken with confirmed that there were more staff when more rooms were occupied.There are senior carers and carers on duty,the home also employs an administrator who has worked at the home for many years,the activities coordinator,head cook and a kitchen assistant and as of the day following the visit two cleaners.There is a maintenance man and the manager was intending to employ a dedicated gardener. Work has been taking place to consolidate and improve the team work amongst staff which had been affected by the lack of a permanent manager. There had been some staff changes since the last inspection and some new care staff had been recruited,three new carers were due to start.The staff group is diverse and Care Homes for Older People Page 23 of 32 Evidence: includes male carers and staff from a variety of ethnic backgrounds and ages.There is a key worker system in place.The manager had put up photos of staff near the entrance so that residents and visitors could identify who was on duty. Three staff files were read,all contained the required recruitment information.One carer was in the country on a student visa that was checked and had some time to run.New staff receive induction and two were at the medication training taking place. Training is given in core and specialist topics,both in house and externally,the training plan showed that core training is updated and there is also training in specialist areas such as dementia awareness,skin care and bereavement and care planning.Staff were positive about the training offered, one said that the company was very good at training and another that training had improved. The head cook had been on training on nutrition and health and dementia awareness.The head cook and administrator clearly enjoy interacting with service users and this adds to the homely feel. The home had less than fifty percent of the care staff who hold an NVQ in care,this needs to be increased,more carers are enrolled on the training. During the visit care and other staff were observed to be attentive to the needs of residents,staff had time to spend with them chatting or doing an activity like a crossword.One survey form from a resident included the comment that care and empathy are shown by the staff. Staff receive supervision from the manager and staff meetings are being held. Care Homes for Older People Page 24 of 32 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 has a warm and friendly atmosphere and there have been improvements to its management and the service as a whole. Internal quality assurance takes place and is being expanded. Records are well maintained and held safely and confidentially. Improvements to the environment and infection control will further protect the health,safety and welfare of residents and staff. Evidence: Care Homes for Older People Page 25 of 32 Evidence: The current manager of the home has been in post since July 2008 and expressed their intention to apply for registration.Until July the home had been without an established registered manager for some time and this was the case at the time of the last inspection when there was an acting manager in post. The manager is experienced and was starting their RMA. The home had been affected by the lack of consistent management and it is evident that since the new manager has been in post there had been a number of positive changes that relate to all the outcome areas inspected .All the previous requirements had been met.The need for some further improvements identified have been costed and raised with senior managers. Staff and service user comments were favourable regarding the management of the home,a staff member commented that the manager was very positive and there had already been changes.One resident put on their survey that -This is one of the best care home I have experienced. The operational manager supports the manager and was at the home during part of the visit undertaking a Regulation 26 visit which was recorded and comments seen. Other quality assurance that takes place is via residents meetings,internal quality assurance surveys,internal managers and organisational audits and social evenings are being started for relatives,the first had taken place recently.The home informs the Commission of matters that we need to know about and its internal processes for sending out this information have been speeded up. The home does not take on any responsibility for residents finances.The day to day accounting for the home is undertaken by the administrator who is very experienced and supports the manager with record keeping in respect of staffing and other documentation.Policies and procedures for the safe and efficient running of the home are in place and available to staff.All records seen were completed to a good standard and confidential information is held securely. A fire practice for staff took place as part of the Regulation 26 visit,fire equipment is regularly tested. The home has a valid insurance certificate and its registration certificate is on display. During the visit safe working practices were seen to be carried out by staff.Improvements are needed to some bathroom areas as identified to make sure that any risk of cross infection is reduced. Overall the quality of the service is improving and work has been done over recent months on areas such as staff accountability,the environment,medication storage,record keeping and improving the quality of life of the residents. The home is in the process of presenting its future business plan and plans for development to stakeholders and its senior members. Care Homes for Older People Page 26 of 32 Care Homes for Older People Page 27 of 32 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 28 of 32 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 15 16 Regulation 16(2)(i) The home must make information on display about the daily menu fully accessible for all service users and the menu must show the correct meal and choices of the day. The weekly and daily menu were not accessible for all service users and did not display the correct meal choices for the day. 01/12/2008 2 19 23 Regulation 23(2) An action plan detailing work that is to take place to improve the environment must be submitted to the Commission by the date given.The plan must address work needed to ensure that service users live in a home that is free from hazards to their welfare,meets their needs and promotes their 31/12/2008 Care Homes for Older People Page 29 of 32 privacy and dignity. The home requires refurbishment,repair and redecoration in a number of areas to make sure that it is suitable for service users and free from hazards to health and safety. 3 21 13 Regulation 13(3) An action plan must be developed for the upgrading of the bath and shower rooms so that service users and staff are protected from hazards and risk of infection in these areas.The plan must be submitted to the Commission by the given date. Bath and shower rooms require upgrading. 4 28 18 Regulation 18(1) Staff must be suitably qualified and trained for the work they are to perform. The home must continue its aim of working towards increasing the number of care staff who hold an NVQ in care at level two or above. 5 31 9 Regulation 8(1) The manager must apply to become registered. 21/11/2008 31/01/2009 31/12/2008 Care Homes for Older People Page 30 of 32 The manager must apply for registration as soon as possible. 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 7 It is recommended that work that has started to make sure that all care plans are signed by residents or their representatives be completed. It is recommended that the temperature in the new medication room be monitored so that it is not kept too hot for safe medication storage. 2 9 Care Homes for Older People Page 31 of 32 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). 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