Inspection on 02/01/09 for Eardley House

This inspection was carried out on 2nd January 2009.

CSCI found this care home to be providing an Adequate 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

Eardley House 21/02/08

Eardley House 21/08/07

Eardley House 05/02/07

Eardley House 30/05/06

Eardley House 29/11/05

Eardley House 08/06/05

Eardley House 30/11/04

Eardley House 11/05/04

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Maple Lodge

Heathlands

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Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Eardley House Moorland View Bradeley Stoke-on-Trent Staffordshire ST6 7NG     The quality rating for this care home is:   one star adequate 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: Pam Grace     Date: 0 2 0 1 2 0 0 9 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. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. 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 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 03000 616161 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Eardley House Moorland View Bradeley Stoke-on-Trent Staffordshire ST6 7NG 01782234530 01782234530 eardley.house@swann.stoke.gov.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Stoke on Trent City Council care home 41 Number of places (if applicable): Under 65 Over 65 41 0 41 41 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: 5 5 0 0 The maximum number of service users to be accommodated is 41. The registered person may provide the following category of service only Care Home only 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 (OP) 41 Physical Disability (PD) over 65 years of age (PD)(E) 41 Dementia over 65 years of age (DE)(E) 41 Dementia (DE) 5 Mental Disorder (MD) 5 Mental Disorder Date of last inspection Brief description of the care home Eardley House is a care home providing both long term and respite care for up to 46 older people with dementia. The home is owned by Stoke on Trent City Council, a Care Homes for Older People Page 4 of 30 Brief description of the care home unitary authority, and care is directly provided by the councils staff team from the social services department. The home is located on the outskirts of the City of Stoke on Trent, in the village of Bradeley. It has ready access to community facilities, including shops, pubs, post office and public transport. The home was originally purpose built to the standards current at the time, and consists of two storeys. Because of its large size, and to meet up to date good practice in care provision, it is now divided into four group living arrangements. Each area has its own living/ dining area. Assisted bathing and toilet facilities are strategically provided throughout the home, and other facilities include a smoke room and separate quiet room with a pay phone. All bedrooms are single. None of the bedrooms have en suite facilities. Access to the enclosed rear garden is from two lounge areas with ramps and handrails provided for safety. The garden has a patio area with seating, flowers and a summerhouse. Overall the accommodation is generally comfortably appointed and welcoming, although there are still some areas of the home that need decorating. Information about the fees charged was not available during this visit and the reader may wish to contact the service to obtain this. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last inspection for this service was 21/02/08. This inspection visit was an unannounced key inspection and therefore covered the core standards. One inspector carried out this unannounced key inspection on one day. We received a total of nine completed surveys from people using the service, their relatives and health professionals. The inspection had been planned using information gathered from the Commission for Social Care (CSCI) database, the Annual Quality Assurance Assessment (AQAA) document that had been completed by the care manager, comments/surveys received Care Homes for Older People Page 6 of 30 from people who use the service and their relatives. On the day of the inspection, the home was accommodating forty one people, including six people receiving short stay/respite care. We spoke with staff, people using the service and their visiting relatives. We also examined records, carried out indirect observation of people who use the service, and staff on duty. Three plans of care and three staff records were examined, we also directly observed daily events. We looked at three bedrooms, two communal lounge areas, the dining area, kitchen, and laundry facilities. We inspected the system of medication administration and storage. Fees are means tested on an individual basis, and range from a zero rating up to 348.00 pounds weekly. The reader may wish to obtain up to date information from the care service. What the care home does well: What has improved since the last inspection? What they could do better: Assessments informing the care plan should be dated, and risk assessments should be kept under review. This ensures the safety of the people using the service. Slips, Trips and Falls should be regularly audited, identifying any common themes, and ensuring the safety of the people using the service. Meetings for people using the service should be established to ensure that people can have their say in regard to activities and the day to day running of the home. More activities should be available for people using the service. Consideration should also be given as to how people are involved in their local community. This ensures that Care Homes for Older People Page 8 of 30 people can follow their hobbies and interests, and maintain links with their community, as they wish. A comprehensive training matrix which covers all staff should be established. This would enable a regular audit of what training is required by staff. There should be effective Quality Assurance systems in place based upon seeking the views of people using the service. Meetings for people using the service and staff meetings should be established to enable feedback. This would encourage people to have their say in the running of the service. Care staff should receive regular and formal supervision at least six times per year as per the National Minimum Standard. This would ensure an informed and well trained staff team. 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.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –03000 616161. Care Homes for Older People Page 9 of 30 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 30 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 considering using the service are provided with helpful up to date information, and can visit and spend time in the home, which helps them to decide if the service is suitable to meet their needs. No person moves into the service without firstly having their needs assessed. Evidence: The Annual Quality Assurance Assessment (AQAA), which was completed by the care manager told us : We invite potential service users to visit Eardley House prior to their admission and go out to assess their needs.We provide a service user guide and a contract. (contract held by finance)each service user is allocated a keyworker and bedroom on arrival. a care plan is set up by the keyworker, families and service users are encouraged to give their input whenever available. an assessment period of six weeks is undertaken with a view to permanent care to ensure the service user is given the best possible care and has been given the appropriate placement. a respite service Care Homes for Older People Page 11 of 30 Evidence: is available.we provide care for elderly service users with dementia type illnesses. We have improved the pre admission visit form, we have introduced a welcome booklet, a picture menu has been incorporated at meal times along with a choice menu form where appropriate. We found that the Statement of Purpose and Service User Guide were readily available, and had been reviewed. People spoken with during this inspection, surveys received, and care plans examined, confirmed that people had been assessed, and had received appropriate information prior to admission. One person said I had help from a social worker, but my family were able to come and see the place before I moved in. This had helped them decide if the service would be suitable for them. We viewed a sample contract, which was a standard format used by the organisation, the care manager confirmed that all people using the service had been provided with a Contract and or Terms and Conditions of Service. Intermediate care is not provided in this home. Care Homes for Older People Page 12 of 30 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 adequate 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 that people receive is based on their individual needs. Risk assessment processes do not fully safeguard people, this needs to be reviewed, to ensure the safety of the people using the service. The principles of respect, dignity and privacy are upheld and put into practice. Evidence: The Annual Quality Assurance Assessment document (AQAA), which was completed by the care manager told us : Service users keep their own General Practitioner if they are within the catchment area or are relocated with a temporary General Practitioner within the area as soon as they arrive. As well as the General Practitioner, district nurses, physiotherapist, occupational therapist, optician, podiatrist, Community Psychiatric Nurse and psychogeriatrians work along side the Eardley House team to give the best possible care for the service users. All managers have attended a medication course and some have completed a level two administration course. All managers follow the policy that is in place. All appointments and treatments are Care Homes for Older People Page 13 of 30 Evidence: documented on the service users individual health care professional sheet, and families are encouraged to attend appointments if they choose to. We have an excellent working relationship with the community mental health outreach team, resulting in consistent approaches to mental health issues within the resident group. a new pharmacist has joined our team, support community outreach psychiatric nurse has been introduced. We examined three care plans, these showed a lack of consistency in regard to the paperwork used, and the quality of the records kept. There is evidence in the care plan of health care treatment and intervention, and a record of general health care information. There are some gaps in information but staff are able to think in a person centred way and are able to give a verbal update.All three care plans had been reviewed, those care plans contained evidence of pre admission assessments, which had informed the care plan. However, one of those assessments was not dated, and there were blank pro formas in some of the care plans seen. There were appropriate risk assessments in place, however, one of the risk assessments had not been reviewed. This was highlighted and discussed with the care manager at the time, and thought to be because the home is currently changing over the paper work for each person. We spoke with staff, people who use the service, and their visiting relatives. People we spoke with and feedback from surveys received, confirmed that people receive the care and health support they need. Comments received included The staff at Eardley House are always very helpful and supportive to my mothers needs, I will never be able to thank them enough for all they do for my mother.Were well looked after here, I havent been well today, but Ive told the carer, and shes going to phone the doctor for me, the carer helps me to get washed and dressed, and keeps an eye on me during the day. We had received a number of notifications from the home since the previous inspection, in regard to falls and trips, by people using the service. This indicated to us the need to audit and monitor those falls, which would in turn identify any common themes. This was highlighted and discussed with the care manager and service manager at the time. The service manager confirmed that the organisation monitors peoples dependency levels. However, it is a recommendation of this report that a regular audit is undertaken, to keep people safe. There was written evidence of health professionals involvement, for example Physiotherapy, Chiropody, General Practitioner visits, District Nurse visits, and hospital appointments. Various aids and adaptations were in use, including raised toilet seats, zimmer frames, and wheelchairs. Care Homes for Older People Page 14 of 30 Evidence: A spot check of medication administration systems, Medication Administration Records, storage and disposal of medication, revealed that there were no anomalies. The homes medication policy is currently under review. Care Homes for Older People Page 15 of 30 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service does not provide adequate social and leisure activities to meet peoples needs. Family and friends are made welcome at the home. Evidence: The Annual Quality Assurance Assessment (AQAA) told us : We offer a flexible and friendly visiting time for families and friends,we try to offer activities that are appropriate for the service users. Service users are offered a choice of menu, and special diets are catered for. Families are encouraged to personalise service users bedrooms. The local clergy visits and is available if requested. Introduced a weekly activity form in the care report folders, made more time in the afternoons for inhouse activities, highlighted individual choices within care plans. Generally, staff are aware of the need to support residents to develop their skills, including social, emotional, communication, and independent living skills. Some people are consulted or listened to regarding the choice of daily activitiy, but this process could be improved. Care Homes for Older People Page 16 of 30 Evidence: We spoke with people who use the service about their daily life, activities, and their outings. They confirmed that activities organised by the home are limited, and that they sometimes dont run activities, depending upon staffing levels. Activities included a fish and chip supper, bingo, movie nights and quizzes. Comments received included I play bingo sometimes, and we watch films every week, My relative has not got any hobbies, if there were things she could do, it would be better for her. But she wont participate in joining in. Feedback from surveys completed by health professionals indicated that there should be more activities provided, and that the television is always on. People spoken with on the day were watching television, and there was little evidence that activities are regularly undertaken. There was also little evidence that residents meetings are being held, which would give people a forum to have their say in what activities are on offer, and a say in the day to day running of the home. We were shown Life Story Books, which are in the process of being completed for people using the service. These go into detail in regard to social history, preferences, hobbies and interests, and will ultimately assist the home in identifying the social needs of individuals. People said that they do have regular visitors, and that they can see their visitors in private if they wish. One person said the family visit on a regular basis so we are always in touch anyway ,my relative keeps her dignity and her independence, and the choices she likes and needs We asked people using the service about their meals, and the menus. People said I enjoy my food, and theres plenty of it, we dont go hungry here, they look after us very well. The new cook said that he intends to introduce a five weekly pictorial menu, with more choice for people. Care Homes for Older People Page 17 of 30 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 service and their family, friends and representatives are given information on how to make a complaint. Complaints and grumbles are acted upon and resolved straight away. Staff understand the need to protect vulnerable adults from all forms of abuse. Evidence: The Annual Quality Assurance Assessment (AQAA) told us: Complaints procedure and policy in place, complaints booklets available by the front door for everyone to see and have if they wish. The office operates an open door policy. All staff have attended the vulnerable adults course, all staff are encouraged to report anything they are not happy with (whistle blowing)all staff have CRB clearance. Due to staff training staff, staff awareness has increased. Surveys received and people spoken with confirmed that they would know how to make a complaint, comments received included, I would go straight to the office, if nothing was done I would report it to Social Services.We know who to complain to, the forms are up on the wall. We usually speak to the carers, and they sort it out.I have never felt the need to make a complaint as we have found the standard of care to be good. If this was not the case we would find out who to complain to. There have been no real concerns. Care Homes for Older People Page 18 of 30 Evidence: We were shown the complaints procedure, which was clearly displayed on the wall in the entrance to the home. The complaints folder showed that no complaints had been received either by the home or by us since the previous inspection. There had been one Safeguarding referral made to Social Services since the previous inspection, correct procedures had been followed, and that referral had been resolved. Staff spoken with confirmed that they had received appropriate training in relation to abuse and the protection of vulnerable adults, and that they would have no hesitation reporting any concerns to the care manager. Three staff recruitment records were examined, they evidenced that security checks had been undertaken in regard to new staff. For example, two written references, a full employment history, identification and Criminal Records Bureau checks. However, one recruitment record showed that only one reference had been undertaken, this was for an employee who had been employed some time ago. This was highlighted and discussed at the time with the care manager, and was not normal practice. This was thought to be an oversight, and will be checked out. Finances were spot checked in regard to personal monies held by the home on behalf of people using the service. These were all in order. Receipts are held for all purchases undertaken, these included hairdressing and chiropody services. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well maintained and comfortable environment, which encourages independence. Evidence: The Annual Quality Assurance Assessment (AQAA) told us : Laundry service provided. Ongoing decoration throughout the home. Families are encouraged to personalise service users bedrooms. Smokeroom available to service users only, all other rooms smoke free. Time release air fresheners situated throughout the home. The building meets fire regulations. Annual PAT testing on all electrical equipment to maintain high standards of safety for the service users and staff. Enclosed garden with seating area. Cleaning schedules carried out by the domestics. Keycoded doors at the end of the corridors, making the environment safer for the service users who are not aware of the risk caused by the stair cases. Some communal areas such as the lounges had been decorated, there were still some areas that looked a bit tired and in need of re-decoration. However, we were told that under the councils improvement plan this building will become a place of excellence, it is generally understood that this will mean a total refurbishment. The environment was clean and homely, and some carpets had been replaced as part of the ongoing Care Homes for Older People Page 20 of 30 Evidence: rolling programme of refurbishment and maintenance. People using the service said that they were comfortable, and had everything they wanted, the chairs in the lounge were comfortable, and there are enough of them. Bedrooms seen had been personalised, and aids and adaptations were seen to be in use around the home for example, raised toilet seats, walking frames, wheelchairs and walking sticks. Bedrooms seen were comfortable and homely. They had been adapted to suit the needs of the individual. Keycoded doors are used, in order to protect people who are not aware of the risk of falls caused by the stairs. There is an enclosed area outside the home that people can safely use whilst sitting outside. The kitchen and laundry areas were clean and tidy, all equipment was in good working order. The AQAA completed by the care manager confirmed to us that health and safety checks had been undertaken. Care Homes for Older People Page 21 of 30 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 receive a service from staff who are well trained and safely recruited. Staffing levels need regular monitoring to ensure peoples needs are met and that they are safe. Evidence: The Annual Quality Assurance Assessment (AQAA) told us : All staff have CRB clearance, all staff have received an induction traing programme. All staff receive supervision, and PDR staff are nominated to attend relevant training courses as they are made available. All staff have contracts, and a copy of the code of conduct. A fair recruitment and selection policy is in place. There are staff nvq trained. There is a 24 hour rota in place. There is a keyworker system in place. Nominated more staff for the nvq, increased training events, set up a more efficient training file log. The service has a recruitment procedure that meets statutory requirements. The procedure is followed in practice and there is accurate recording at all stages of the process. There is acceptable use of any agency or temporary staff which doesnt adversely affect the quality of the individual care and support that people receive. The Dependency Levels of people using the service have been more closely monitored Care Homes for Older People Page 22 of 30 Evidence: since the previous inspection. Staffing levels have been adjusted accordingly, and there has been an overall reduction in the bed occupancy of the home. The staff rota evidenced that staffing levels had been maintained. However, comments received indicated a need for more staff when people have more complex needs, and their dependency levels increase. Staff interviewed confirmed that they had received appropriate training, including adult protection, fire, moving and handling, food hygiene, control of substances hazardous to health (COSHH), and dementia awareness. Individual training records and Certificates evidenced that these courses had been undertaken. We discussed the need for the service to have a comprehensive and up to date training matrix, as it was difficult to ascertain what training had been undertaken by staff via individual records. Staff spoken with could not remember when they had last attended a staff meeting and or undertaken formal supervision. It is recommended that all care staff should have formal supervision at least six times per year, as per the National Minimum Standard, and that regular Staff Meetings should be established. Surveys received from people using the service confirmed that staff listen and act on what they say, and staff are available when you need them. Comments included They do as much as they can, my relative really likes it a lot.they seem to be well trained and efficient in what they do, the home seems to cater very well for different disabilities and ages, I think the staff do a very difficult job, very well. Care Homes for Older People Page 23 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect. Monitoring, quality assurance processes, and staff supervision would ensure that the service is better operated in the best interests of the people who use it. Evidence: The Annual Quality Assurance Assessment (AQAA) told us : Care manager trained to NVQ 4. Assistant managers receive regular training in medication administration and other various appropriate courses. Policies and procedures in place to safeguard service users and their finanaces. Business support continue to assist us with financial issues for service users. Improved filing systems. The Annual Quality Assurance Assessment (AQAA) was adequately completed by the care manager, and returned to us on time. All sections of the AQAA were completed and the information gives a reasonable picture of the current situation with the service. The evidence to support the comments made is satifactory, although there are Care Homes for Older People Page 24 of 30 Evidence: areas where more supporting evidence would have been useful to illustrate what the service has done in the last year, or how it is planning to improve. The AQAA gives us some limited detail about the areas where they still need to improve. The ways that they are planning to achieve this are briefly explained. The data section of the AQAA was completed. The AQAA also confirmed that Health and Safety checks had been undertaken. The environment is safe for people and staff because appropriate health and safety practices are carried out. We are kept informed via Regulation 37 notifications of incidents in the home. However, there had been a number of notifications received in relation to trips, slips and falls affecting the people using the service. This would indicate the need for a regular audit by the care manager, and would ensure the safety of individuals using the service. This was a recommendation of this report. Relatives and people using the service were complimentary of the staff and management, and positive comments were received in regard to the commitment, care and support that they and their relatives received. We are kept informed via Regulation 37 notifications of incidents in the home. However, there had been a number of notifications received in relation to trips, slips and falls affecting the people using the service. This would indicate the need for a regular audit by the care manager, and would ensure the safety of individuals using the service. This was a recommendation of this report. There had been one Safeguarding referral made since the previous inspection. This was dealt with correctly by the service to protect the person concerned. Staff recruitment files that we saw show that good recruitment systems are in place, which means that only suitable people are appointed to work at the home, safeguarding the people who live there. We noted that there is a regular audit of Dependency Levels in regard to the people using the service, this enables staffing levels to be more accurately maintained. The staff rota for the month of December 2008 evidenced that staffing levels had been maintained. Staff spoken with confirmed that appropriate staff training had been undertaken, however, staff could not recall when they last had supervision, and or had attended a staff meeting. Staff should have formal and regular supervision as per the NMS. Staff meetings should be held regularly. These shortfalls were highlighted and discussed at the time with the service manager and care manager. Recommendations were made Care Homes for Older People Page 25 of 30 Evidence: as per this report. Quality Assurance was also highlighted and discussed with the service manager during our visit. Although the organisation usually undertake this on an annual basis. This had not been undertaken in 2008. It is therefore a recommendation that effective quality monitoring systems are put into place, based on seeking the views of people using the service. The outcome of this should be fedback during peoples and staff meetings. Finances were spot checked in regard to personal monies held by the home on behalf of people using the service. These were all in order. Receipts are held for all purchases undertaken, these included hairdressing and chiropody services. Care Homes for Older People Page 26 of 30 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 27 of 30 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 1 7 Assessments informing the care plan should be dated, and risk assessments should be kept under review. This ensures the health and safety of the people using the service. Slips, Trips and Falls should be regularly audited, identifying any common themes, and ensuring the health and safety of the people using the service. Regular meetings should be established for people using the service, to ensure that people can have their say in regard to activities and the day to day running of the home. This enables people to make choices about their life style, and gives support to people wishing to develop their life skills. More activities should be available for people using the service. Consideration should also be given as to how people are involved in their local community. This enables people to make choices about their life style, and gives support to people wishing to develop their life skills. A comprehensive training matrix which covers all staff should be established. This enables monitoring of training already undertaken by staff. 2 8 3 12 4 12 5 30 Care Homes for Older People Page 28 of 30 6 33 There should be effective Quality Assurance systems in place based upon seeking the views of people using the service. Peoples and staff meetings should be established to enable feedback from quality assurance surveys. Care staff should receive regular and formal supervision at least six times per year as per the National Minimum Standard. This ensures a stable staff team who are trained and skilled to support the people who use the service. 7 36 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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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