Inspection on 22/01/09 for Eothen

This inspection was carried out on 22nd January 2009.

CSCI found this care home to be providing an Excellent 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

Eothen 24/01/07

Eothen 17/11/05

Eothen 11/05/05

Eothen 18/10/04

Eothen 26/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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: Eothen 45 Elmfield Road Gosforth Newcastle Upon Tyne Tyne & Wear NE3 4BB     The quality rating for this care home is:   three star excellent 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: Elaine Malloy     Date: 2 9 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 0870 240 7535 (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.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Eothen 45 Elmfield Road Gosforth Newcastle Upon Tyne Tyne & Wear NE3 4BB 01912130707 01912130075 enquiries@eothenhomes.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Eothen Homes Limited Name of registered manager (if applicable) Sylvia Ann Dixon 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: Date of last inspection Brief description of the care home Eothen is a purpose built care home that is situated in a residential area of Gosforth. It is close to a range of shops and other local amenities. The home provides personal care and support to 37 older people. It is equipped with a passenger lift. There are 35 single bedrooms and one double bedroom, all with en-suite facilities. Communal lounge and dining areas are provided. There are baths and showers, and separate toilets. The home has car parking space and accessible attractive gardens. A guide to the homes services and inspection reports are readily available at the home. The current weekly fee is £469.00 single occupancy, £522.00 for a single person occupying a double room, and £375.00 for couples or relatives sharing a double room. The rates are the same for people who are privately funded or funded by the Local Authority. Care Homes for Older People Page 4 of 30 0 Over 65 37 care home 37 Brief description of the care home 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: three star excellent 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 3 star. This means the people who use this service experience excellent outcomes. The inspection was carried out by: Looking at information received since the last inspection on 24th January 2007. Getting the providers view of how well they care for people. An inspector visiting the home unannounced on 22nd January 2009. Getting the views of people who use the service and staff by talking to them and from Care Homes for Older People Page 6 of 30 surveys they completed. Talking to the senior management about the service. Looking at records about the people who live at the home and how well their needs are met. Looking at a range of other records that must be kept. Checking that staff have the knowledge, skills and training to meet the needs of the people they care for. Looking around the building to make sure it is clean, safe and comfortable. The inspection was completed over 8 hours. We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the care home does well: What has improved since the last inspection? An active approach is taken to developing the service and being involved in initiatives that benefit people living and working at the home. This has resulted in the following improvements: Better planning around the process of assessment and admission of new residents. Care Homes for Older People Page 8 of 30 Employing an activities co-ordinator who has significantly improved the range of activities, events and outings for peoples social stimulation. Introducing a physiotherapy group that provides exercise to improve physical strength and prevent falls. Committing to a national challenge to respect the rights of people to be cared for with dignity and treated as individuals. Asking people about their favourite meals and including these in the menus, and joining an association that promotes best practice in catering to meet peoples dietary needs. Further improvement to the environment including update of the passenger lift, creating a private lounge area, and refurbishing the ground floor corridor, the laundry and a sluice. Three new height adjustable baths were installed. A loop system has been fitted in the lounge to assist people with hearing impairments. Staff have received additional training to keep them up to date with legislation such as the Mental Capacity Act and how this will affect their practice. The home has also addressed recommendations from the last inspection to evaluate care plans monthly, and review and update policies and procedures. 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 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have a comprehensive assessment of their needs and are assured these can be met before moving into the home. Evidence: The home has a clear process for the admission of a new resident. Care records showed that a thorough assessment of the persons needs is carried out. This includes personal history, medical history, a daily living assessment, mental test score, beliefs, religion, disability, and any specific requests. Information is also obtained from the persons doctor and if applicable, from other medical professionals. A care management assessment is provided from social services where the persons care will be funded by the Local Authority. Following the assessment the General Manager checks and approves the persons application to make sure his/her needs can be met at the home. Prospective residents Care Homes for Older People Page 11 of 30 Evidence: are encouraged to spend time at the home getting to know other residents and staff. Records of visits prior to admission are kept. Each person is allocated a named member of staff as their key worker to ensure continuity. Most people told us that they received enough information about the home before they moved in, so they could decide if it was the right place for them. One lady indicated that her daughter had viewed several local care homes. She said, Everyone thought this was the best. Another person said, I knew as soon as we walked through the door. A lady who had moved into the home recently said, I give the home a gold star. Staff told us they are always given up to date information about the needs of the people they support. One person said, All care plans are updated regularly with all the needs of each resident. Another staff member indicated that staff are informed immediately when a residents needs change. Staff said there is enough staff to meet the individual needs of the people living at the 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with individually tailored care and support that meets their health and personal care needs and fully respects privacy and dignity. Evidence: A good range of assessments is completed and updated regularly to identify each persons current needs. Some of the assessments, such as nutrition and social also indicate the residents preferences. Records showed that people have individual care plans to address identified needs. The plans are generally well recorded and personalised with specific interventions to guide staff on how best to support the person whilst maintaining his/her dignity and independent skills. Plans are in place for physical and mental health needs, personal care, social and spiritual needs, and night care. One persons care plans had been updated to reflect their increased frailty. Staff are now evaluating the care plans on a monthly basis, as recommended at the last inspection. People living at the home told us they always receive the care and support they need, Care Homes for Older People Page 13 of 30 Evidence: including medical support. One person described settling well at the home and said staff are very kind and understanding. Another person said, The care workers are excellent. Staff told us the ways they pass information about the people living at the home between staff works well. One person said, A hand over is given before and after each shift. People living at the home have a choice of doctor and use eight GP practices. District nurses visit individuals as needed. Psychological support is provided by mental health professionals and, where necessary, behaviour specialists. Arrangements are in place for people to access a range of NHS and private health care professionals and all contact is recorded. Details are kept of each persons medical history. Care plans are recorded to address physical and mental health needs such as diabetes, depression, moving and handling, sensory impairment, pressure area care, and continence. The management monitor residents dependency levels each month. This enables prompt reassessment to be requested from health and social care professionals where a persons needs have changed. The home has introduced a weekly physiotherapy group that aims to promote peoples physical strength and prevent falls. Themed sessions are held, for example sit and get fit, chair based exercises. Physiotherapy can also be provided to individual residents. The manager aims to maintain good working relationships with professionals and has started to have meetings with District Nurses and the local Pharmacist on a quarterly basis. All residents are offered the choice to retain responsibility for taking their own prescribed medication. Some people have continued to self-administer as required inhalers and sprays, and creams and ointments. There is a medication policy and procedures for staff to follow to make sure medication is given safely. Designated shift co-ordinators only give out medication and each of these staff members has completed medication training. Their competency is also assessed each year. The home uses a monitored dosage medication system and printed medication charts with directions are provided by the pharmacist. Each person has a photograph on his/her chart for identification purposes. Medication records, including the register for Controlled Drugs were appropriately recorded. A full medication audit is carried out every six months. People are asked how they wish to be addressed and their preferred name is recorded Care Homes for Older People Page 14 of 30 Evidence: on their care record. Residents confirmed that all personal care and treatment is carried out in private. The majority of bedrooms are single occupancy and people are offered keys to their room and have a lockable piece of furniture. There is one shared bedroom that is currently occupied by a married couple. Two bedrooms with an adjoining door are also available. All bedrooms have en suite facilities. People are provided with their own telephone with direct line number and separate billing. Privacy and dignity issues are built into individual care plans. The home has signed up to the dignity in care challenge. This is based on national expectations of what constitutes a service that respects peoples dignity. All staff carry challenge cards that set out the ten different aspects of dignity. For example treating each person as an individual and supporting people with the same respect you would want for yourself or a member of your family. Training sessions have taken place on the challenge and how staff can incorporate the principles into every day care practice. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are very well supported to live their preferred lifestyle, exercise choice and control over their lives and meet their social and dietary needs. Evidence: Care records showed that people have an assessment of their social needs, a personal profile and a diary of the activities they have participated in. Maintaining contact with family and friends is built into individuals social care plans. Residents told us that there are activities arranged by the home that they can take part in. One lady indicated she likes to paint and draw in her room. Another person said, I enjoy the outings, crafts, the choir and church services. The home has employed a part time Activities Co-ordinator. Two residents were involved in interviewing applicants for the post. The co-ordinator has spent time getting to know residents and has made lots of progress in planning and organising stimulating activities and events. She has also forged better links with the local community, for example residents are using local amenities more often and individuals and groups are invited into the home to give demonstrations and talks. Staff told the inspector that the co-ordinator has made a significant difference to the social life Care Homes for Older People Page 16 of 30 Evidence: within the home. Programmes of activities are arranged on a weekly basis and a copy is given to each resident so they choose what they wish to take part in. A very good range and variety of activities is being provided. The current programme included bible study, arts and crafts, various games, clubs for classical music and current affairs, have a go at line dancing, films, a golf presentation, and a reminiscence session. Weekly outings are organised to destinations of residents choice. Recent trips included the Laing Art Gallery, Tynemouth, and a garden centre. There are also plans for the home to twin with another charitable care home in Newcastle so people can visit and take part in joint events such as coffee mornings. The Activities Co-ordinator keeps an activities file with details of all activities and outings. She records contact details, comments on the venue, access, and peoples level of enjoyment. She also records a weekly summary for each person about the activities he/she has engaged in, including one to one time with the co-ordinator and staff. The organisation has become a member of a national association of providers of activities that provides relevant training, including training that leads to qualifications in the provision of activities. In 2008 residents and staff took part in A breath of fresh air project, the aim of which was fresh air for all. They concentrated efforts on gardening, growing herbs and vegetables, and this included trips to a garden centre. Details of the project have been kept in a book with photographs. The home works to the principle that people are encouraged to keep control of their lives, make their own decisions and stay as independent as possible. For example, one person told the inspector that they continue to lead the lifestyle they choose whilst appreciating the support that is given. Another person said they like the flexible routines of the home and confirmed they are offered choices and make their own decisions. Management reported there is good support from relatives and friends, and where necessary relatives advocate on behalf of their family member. Information on external advocacy and advice services is also available. The home has policies and procedures on record keeping, including confidentiality and access to personal records. People are shown and have their care plans explained to them, and sign to agree the content of their plans. Residents and their family are invited to attend individual reviews of their care. Care Homes for Older People Page 17 of 30 Evidence: The extent of personal possessions that people wish to bring into into the home is agreed with management. Some residents continue to manage their own personal finances and retain the services of their solicitor. Cash can be held in the homes safe for safekeeping. Each person has an assessment of his/her nutritional needs and is asked about their food preferences. Weights are monitored at least monthly and new sitting weighing scales have been purchased. People can take meals in their room if they wish and times of meals are flexible. Special occasions, celebration of events and special diets are catered for. The kitchen was awarded a 5 star rating following an inspection from Newcastle Environmental Health. The facilities are planned to be refurbished this year, with installation of stainless steel shelves and units, and replacing the flooring. The chef is booked to attend advanced food hygiene and nutrition training. Catering staff have meetings with management and are in the process of including residents favourite meals into the menus. The organisation has joined the National Association for Care Catering. Staff attend regional meetings and receive information, including catering for the nutritional needs of older people. People are provided with a varied diet with choice of meals and alternatives can be requested. The four week menu offers cooked breakfast daily, with porridge or cereals, toast, and fruit juice. There are at least two choices of meals at lunch, including a vegetarian option, and two choices at tea. Different snack suppers are served. Staff record a food report each day details of what people have enjoyed, what was popular, and comments from residents. People told us that they like the meals at the home. Comments included, Could not be better, the chef is most obliging, Excellent chef, no complaints, and Very good. The inspector dined with residents and a visitor at lunch. The dining tables were nicely set and condiments were available. The meal was nicely presented and of a generous portion size. Vegetables and gravy were served separately for people to help themselves. Lunch was a choice of chicken or vegetable curry with rice, or gammon, pineapple, potatoes, broccoli, and turnip, followed by apricot crumble with either custard, cream, or ice cream. Hot and cold drinks were provided. The meal time was very relaxed and staff were helpful and offered discreet assistance. Residents and the visitor said the food was lovely. One person told the inspector, The chef will do anything you ask. Care Homes for Older People Page 18 of 30 Care Homes for Older People Page 19 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are properly protected from being harmed by effective procedures for making complaints and safeguarding vulnerable adults. Evidence: The home provides people with a copy of the complaints procedure in the guide to services. Details of the complaints process are also available in the reception area and on a noticeboard. Residents told us they know who to speak to if they are not happy, and how to make a complaint. One person said there is an open door policy and another said, I would speak to the manager if I had a complaint. Staff said they know what to do if a resident, relative, advocate or friend has concerns about the home. Records of comments and compliments about the service are kept, including cards and letters. Two complaints have been logged in the past year. Both were appropriately recorded and responded to, including a letter of response. There are policies and procedures on recognising and preventing abuse, protecting vulnerable people, and whistle blowing, (informing on bad practice). All staff have had safeguarding training and the manager has improved her experience of adult protection procedures. Care Homes for Older People Page 20 of 30 Care Homes for Older People Page 21 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a clean and comfortable home that is decorated and furnished to a high standard and properly equipped to meet their needs. Evidence: The home is kept very clean, and decorated, furnished and equipped to high standard. People are encouraged to personalise their bedrooms and can choose the decoration. Equipment is provided for individuals to enable them to retain independence, such as pendants linked to the call system. Regular checks are carried out to make sure the environment is safe and properly maintained, and that any repairs needed are reported promptly. Residents also have access to well kept and attractive gardens. In the past year a number of improvements have been made in the building. These include provision of a loop system in the lounge to aid people with hearing impairments. A private lounge area has been created to give people more choice of communal space, and new curtains for the lounges. Three height adjustable baths were installed. The passenger lift has been updated to comply with the latest regulations. The ground floor corridor was redecorated and has new carpet and curtains. The laundry and a sluice were refurbished. Care Homes for Older People Page 22 of 30 Evidence: There are also plans for the coming year that include an extension of the main lounge area, updating the emergency light system, refurbishing the kitchen and a sluice, and improving access to the garden through French doors. Residents told us that the home is always fresh and clean. There are procedures for staff to follow on controlling the risk of infection. The majority of staff have completed infection control training. All bedrooms have en suites and suitable hand washing facilities are provided throughout the home. Care Homes for Older People Page 23 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care workers are employed using a robust recruitment process and are properly trained to be skilled and competent to meet peoples diverse range of needs. Evidence: The home continues to provide staffing levels of at least five carers on duty across the waking day, and two carers at night. Additional carers are included on the rota when needed, such as accompanying a resident to an appointment, and when a resident requires extra care. The managers hours are additional to these levels. On each shift a worker is designated in charge of co-ordinating the care. The activities co-ordinator works 20 hours each week. There is a good ratio of weekly catering, domestic, laundry and gardener/handy person hours. People living at the home told us that staff are available when they need them and listen and act on what they say. Staff told us they received good induction and ongoing training, and have regular support from their manager. All said they are provided with training that is relevant to their role, helps them understand and meet individual residents needs and keeps them up to date with new ways of working. Staff said they feel they have the right support, experience and knowledge to meet the different needs of people living at the home. Comments included, I wouldnt work anywhere else, It is a very good organisation, very supportive, Staff are good at meeting the Care Homes for Older People Page 24 of 30 Evidence: needs of every aspect of care, and, I am doing a palliative care training course that consists of four units and is very good. It covers religion, race, ethnicity and disabilities. A domestic staff member told the inspector she makes time to get to know residents, and their preferred routines for cleaning. Over 50 percent of care staff have achieved National Vocational Qualifications (NVQ) in care at levels 2 and 3, and two care co-ordinators have achieved level 4. The home has its own NVQ Assessor. Further staff are currently studying for care qualifications. A sample of staff recruitment files was examined. These showed that all necessary information is obtained and thorough vetting is carried out before a new member of staff is appointed. All staff are employed subject to Criminal Records Bureau (CRB) checks. A recruitment checklist is maintained and the General Manager monitors all recruitment details. New carers are provided with induction training to Common Induction Standards over a period of 12 weeks. Each area of this training is linked to the homes own policies and procedures. Following induction the individuals further training needs are identified and relevant courses are arranged. The home has good links with training providers and the manager is a member of the network board for the Tyne and Wear Care Alliance, a local training and development organisation. A training programme is maintained with details of courses that all staff have undertaken and training that is planned. Individual training records and certificates are also kept. Training in the past year has included safe working practices, medication, Mental Capacity Act awareness, infection control, dignity challenge, nutrition, falls prevention, and equality and diversity. Records of in-house training sessions need to be kept to reflect the full extent of training provided to staff. Care Homes for Older People Page 25 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home are provided with a quality service that is managed in their best interests and promotes their safety and welfare. Evidence: The Registered Manager, Mrs Sylvia Dixon has managed the home for three years. She is a Registered General Nurse and has achieved the Registered Manager Award qualification. All of her working hours are in addition to the staffing levels. Mrs Dixon is supported in her role by the management team and senior managers within the organisation. The home works to an annual business plan with targets to ensure the quality of the service is maintained and improved. This sets out the actions required, how these are measured and the desired outcomes. The plan is reviewed every three months. A range of methods are used to monitor quality including a range of audits and monthly conduct of home visits and reports by senior management. People living at the home Care Homes for Older People Page 26 of 30 Evidence: and their relatives are consulted about the service through surveys and meetings. Their views have been acted upon and have resulted in changes to the provision of social activities, the introduction of a weekly physiotherapy session, peoples favourite meals being incorporated into the menus and improvements to communal space in the home. The majority of the homes policies and procedures have been revised in the past year and new policies have been introduced. Records are maintained of cash held for safekeeping. These are appropriately documented on individual account sheets. Two signatures are recorded to verify each transaction and numbered receipts for purchases are kept. Weekly checks of balances and cash are carried out. The home has a manual of health and safety policies and procedures. All staff are provided with training on health and safety and safe working practices. Risk assessments are in place for safe systems of work within the home. Risks are also identified according to individual residents vulnerability. Strategies are developed to manage risks such as bathing independently, choking, risk of falling and risks associated with mental health frailty. All fire safety checks, tests and instructions to staff are recorded as being carried out at the required frequency. The home has systems for the reporting of accident and incidents. The manager is revising how accidents are analysed to provide more meaningful monitoring. Care Homes for Older People Page 27 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 28 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 30 In house training sessions should recorded to demonstrate the full range of training provided to staff. Care Homes for Older People Page 29 of 30 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 © (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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