Inspection on 19/01/09 for Glen Rosa & Kitwood House

This inspection was carried out on 19th January 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glen Rosa & Kitwood House 13/02/07

Glen Rosa & Kitwood House 08/02/06

Glen Rosa & Kitwood House 13/07/05

Glen Rosa & Kitwood House 23/12/04

Glen Rosa & Kitwood House 01/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 20/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Glen Rosa & Kitwood House 24 Grove Road Ilkley West Yorkshire LS29 9PH     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: Caroline Long     Date: 2 1 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. 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 31 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 31 Information about the care home Name of care home: Address: Glen Rosa & Kitwood House 24 Grove Road Ilkley West Yorkshire LS29 9PH 01943609604 01943817363 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Susan Sullivan Type of registration: Number of places registered: Methodist Homes for the Aged care home 47 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: Date of last inspection Brief description of the care home Glen Rosa and Kitwood House are owned and run by Methodist Homes for the Aged, which is a national voluntary organisation. The home provides care for older people and people with demenia. Glen Rosa is the main building that has been converted and extended and provides accommodation for thirty-three older people. The extension, Kitwood House has been built for the purpose of providing care to fourteen older people with dementia. Glen Rosa and Kitwood House are situated on Grove Road in Ilkley, close to the town centre and public transport. The house is situated in large, well-maintained grounds and gardens which provide ample car parking. There is ramped access to the side of the building that provides access for those using mobility aids. The Inspection report is displayed in the ground floor communal area. Care Homes for Older People Page 4 of 31 Over 65 14 33 3 0 0 0 Care Homes for Older People Page 5 of 31 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: What we did to make this report Information provided by the manager on 26th January 2009 indicated that the current weekly fee for the home is from four hundred and ninety to five hundred and fifty five pounds per week. Additional costs include the provision of extra support by staff, toiletries, hairdressing, holidays, leisure activities and clothes. This is what we used to write this report. We looked at information we have received about the home since the last key inspection. Care Homes for Older People Page 6 of 31 We sent surveys to people living in the home and to health professionals. Five surveys were returned by people living in the home and one by a health professional. One inspector visited the home unannounced. This visit lasted over six hours and included talking to the staff and the registered manager about their work and the training they have completed, and checking some of the records, policies and procedures the home has to keep. We spent time talking with people who live in the home and two relatives and a health professional who was visiting. We looked at three peoples care records to check that a plan had been formulated which helped staff provide support to people according to their needs and wishes. We focused on the key standards and what the outcomes are for people living in the home, as well as matters, which were raised at the last inspection. 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? 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 Care Homes for Older People Page 8 of 31 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 31 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 31 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. To be sure Glen Rosa and Kitwood House are the best place for people to live, an assessment of their needs will be carried out before they move in. Evidence: Information is made available to anyone interested in moving into the home. Usually the registered manager will visit them at their home and complete an assessment to make sure Glen Rosa and Kitwood will be able to provide a service that will meet the persons needs. Where possible the person is then encouraged to visit the home, for a day or overnight providing them with the opportunity to meet everyone and to get a feel for the home. Three peoples files who had recently moved into the home were looked at in detail all confirmed good practice. All the assessments were carried out before people moved into the home and all contained details of every aspect of their daily life and health Care Homes for Older People Page 11 of 31 Evidence: needs. Examples of the information included were religion, daily living, social interests, and nutrition. The records also contained information from other health professionals that had been obtained before the person moved into the home. Both the pre assessment and the information from the health professionals would have enable the registered manager to make a informed decision about whether the home has the staff skills and equipment necessary to look after the person properly. One person and a relative both told us they had visited the home before they moved in and an assessment of their needs had been carried out by senior staff. The staff told us they had the necessary training to enable them to look after people properly. Some of the staff had also recently competed a training course on dementia care. Five people who returned their surveys stated they had received enough information before they moved into the home and comments made were:Given a Methodist Homes brochure, interview and discussion with senior staff who were most helpful. A relative also told us they had received information about the fee structure so they could see exactly what the charges were, they told us I trust them absolutely. During our visit we had a discussion with the registered manager about what two peoples care needs were when they moved into the home. Following our visit the registered manager has sent us information which clarifies what care and support these people needed when moving into the home. The registered manager should be mindful that people who move into home always meet the registration categories. The home does not provide intermediate care. Care Homes for Older People Page 12 of 31 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. Peoples health and personal care needs are generally met, in a way that maintains their dignity and independence. Evidence: The home is split into two units Kitwood House which is for fourteen people with dementia and Glen Rosa which provides personal care for older people. Three people living in Glen Rosa said staff respected their privacy and dignity. They were able to give examples as to how staff did this. Staff were observed providing support in a kind and helpful manner and people were clean and dressed in coordinating clothes. A relative confirmed this was normally the case. Also on Kitwood House which is the dementia unit the atmosphere was calm and we saw people appeared comfortable, and looked happy and content. People who returned their surveys were asked do you receive the care and support Care Homes for Older People Page 13 of 31 Evidence: you need three stated always, two stated usually. Examples of comments made were: Very happy here. The care and support received depends mainly on the staff some care, some do not. A relative described how their relatives health had improved since moving to the home. Three peoples case records were looked at in order to check that a plan had been formulated which helped staff provide support to people according to their needs and wishes. All contained care plans that covered aspects such as daily living, catering, spiritual, religious needs, social activities, emotional needs and medication. These were supported by risk assessments, which described the possible risks to people, and the actions the staff needed to take to minimise these risks. Both the care plans and the risk assessments were evaluated by staff regularly, some daily. When the plans were written they contained peoples personal preferences but they lacked the actions the staff needed to take. They also lacked some important details such as if the staff needed to record the persons weight or their fluid intake etc. We found although the plans were evaluated the initial plans were not changed to reflect the evaluation. An example of this is a plan was written in April 2008 for one person when they moved into the home and describes how they can move around the communal areas with the help of two walking sticks. A risk assessment carried out in December states they now need assistance and the staff told us they use a wheel chair to move around in the communal areas, however this was not in the initial plan. The staff explained this may have been written on the evaluation sheet but these sheets had been archived, this means this information would not have been available to anyone new staff. The staff also completed a daily report where they write the numbers of the plans they had evaluated. However these did not provide staff with a way of tracking any changes in a persons needs because they referred to numbers of the care plans only. A member of staff also explained that for some staff English was not their first language and so they had found difficulty in writing the care plans and people told us how they sometimes had difficulty in making their requests understood. Care Homes for Older People Page 14 of 31 Evidence: However talking with the registered manager, a team manager and the staff evidenced they are aware of peoples care needs and personal preferences and are proactive about identifying any changes and consulting with health professionals. The care staff also explained they have hand overs at the beginning of a shift where they are updated about peoples needs. Also when questioned staff were able to confirm they were assessing any risks to people and regularly making sure that people were safe. Peoples health care needs are promoted and maintained. The records showed people were accessing health care professionals, such as General Practitioners, Chiropodists, and District Nurses. The relatives also said people receive the medical support they need. We saw doctors visiting people and a health professional told us the staff were very good at informing them of any changes in a persons condition. However we did see that the GP saw the person in the communal lounge, this does not promote a persons privacy or dignity. At the previous inspection we asked the manager to ensure the practice of administration of medication by staff is safe. When we visited the registered manager explained for those people who look after their own medication, risk assessments are in place and the home helps them monitor their stocks. The staff told us only the senior staff administer medication and they have completed their medication training. A monitored dosage system is used and the staff were able to explain the system for administering the medication fully. However when we looked at a sample of medication we found there were two discrepancies in the mediation records. The registered manager agreed to immediately looked into the reason for these and take any actions necessary. Care Homes for Older People Page 15 of 31 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. Improvements need to be made to make sure everyone is offered appropriate activities of their choice. People are given a choice of nutritious drinks and meals when they request them. Evidence: The atmosphere at the Glen Rosa and Kitwood House was very calm and relaxed. Visitors told us how they were made very welcome by the staff and were kept well informed. People can sit in communal lounges or spend time in their rooms and can rise and retire as they wish. We saw in both Glen Rosa and Kitwood House people had access to their rooms throughout the day. At Kitwood house we were able to see that people were helped to take part in activities of their choice. The staff were able to tell us about a variety of activities that they carry out with people and we were able to see in the communal lounge there were various magazines, newspapers and the staff were playing music which people liked. Care Homes for Older People Page 16 of 31 Evidence: A relative from Kitwood house also confirmed there was always a calm atmosphere and music playing and how the television is used in a tempered way to suite peoples preferences. Also how people can wander around the unit and the bedrooms are not locked and people were provided with enough stimulation. The team manager also told us how she completes activity sheets in Kitwood House, so she knows what activities people have taken part in. She explained she likes to offer short sessions for each activity which last about twenty minutes. Also how people have memory boxes and the staff ask relatives to bring in familiar objects. During the summer they take people out for a walk around the community and how some people enjoy the enclosed garden. She explained how activities on Kitwood House are suited to peoples individual needs. At Glen Rosa we found some people told us they were happy and liked to remain in their rooms. The registered manager told us they do not have a activities co-ordinator but are trying to recruit one. Whilst this is happening she has designed a programme of activities for staff to carry out with people in a morning and afternoon in the lounge at Glen Rosa. However the staff explained due to lack of time they find this difficult. There was also a trip arranged to the pantomime and the registered manager told us over Christmas choirs had visited the home. Four people living in Glen Rosa and a relative told us that there are no or very limited activities in the home. An example given was one of the activities on the list was the shop but this only lasted ten minutes and was where staff sold sweets and shampoo from a trolley. They described how there are only very occasional trips into the community. Two people described how they had active lives before moving into Glen Rosa but found the home did not provide them with the opportunity to continue this. In the survey we asked are there activities arranged by the home that you can take part in four stated there were activities only sometimes at Glen Rosa. Examples of comments were:This is very ad hoc. There is no one person employed to do activities and some are inappropriate for some residents, there is little variety. Another told us about how the activities had been something to look forward to but how they had declined and now we are missing what we had and we sit daily in gods Care Homes for Older People Page 17 of 31 Evidence: waiting room. When we visited one of the communal lounges in Glen Rosa was being decorated. We saw many people were sat in a semi circle around a television. During the morning we were told that a member of staff read a newspaper to people and in the afternoon we saw the shop where staff sold sweet, shampoo from a trolley. At tea time we went into the lounge and found the TV had Childrens television on. However two people explained they are part of a residents committee where they were able to make their views about the home known. We were also told by people there is a church service once a week and communion once a month. Five people who returned their surveys told us they either always or usually liked the food. Three people also told us the food was very good. Two people also told us how when they had been unhappy with the food, their views had been heard and changes had been made. People either eat in their room, in the communal dining rooms on Kitwood House or Glen Rosa, meals were seen as an occasion where people can meet and talk. However people explained the following the recent changes of dining furniture at Glen Rosa both the tables and chairs were no longer comfortable. Examples given were the tables were too small to fit four people around and the chairs were too high and the seats not wide enough. The registered manager explained this was being addressed by the organisation. Care Homes for Older People Page 18 of 31 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 are able to express their concerns and are safeguarded from harm. Evidence: Although we were told by people they generally know who to speak to and would know how to complain. Comments made were the management were slow to respond and Many residents say nothing because they fear they will be considered a nuisance or that there could be retribution. In kitwood House the staff told us if a person was unable to make their concerns known verbally they would be able to see if people were unhappy by their behavior. A comment made by a relative supported this:Staff are sensitive to the needs of Alzheimers residents, in spite of the difficulty some resident have in expressing themselves. We were able to look at the complaints records in the home we found the home have had various concerns about the dining room furniture, and the use of staff where English is not their first language. These had been investigated and responded to by the registered manager or the district manager. Care Homes for Older People Page 19 of 31 Evidence: There are regular meetings in the home where people can make their views known. Discussion with the registered manager showed she was aware of the actions to take to safeguard adults. She also explained she is the person who carries out staff training at the home about safeguarding people and most of the staff have received training in adult protection and safeguarding issues. Three staff told us they were aware of whom to alert if an incident occurred. Although the registered manager trains staff in the home about vulnerable adults, she has not attended the local authorities training for managers about reporting abuse. We would recommend she attends this training so she up to date with the local procedures. Care Homes for Older People Page 20 of 31 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 home is decorated and furnished to a high standard and provides a comfortable, safe and very pleasant place for people to live. Evidence: The home is comfortable and clean. Three people living in the home a relative and three people who returned their surveys told us this was normally the case. A comment made in a survey was Excellent environment. Spacious en suite rooms. Communal room cosy and comfortable. The home is split into two units Kitwood House which is for fourteen people with dementia and Glen Rosa which provides personal care for older people. People said their rooms were clean, and comfortable, they liked them and they are decorated and furnished to their personal interests and tastes. All the bedrooms are en-suite. Both Kitwood House and Glen Rosa have a communal lounge and dining area. People have access to a large garden and patio at Glen Rosa and an enclosed garden for Kitwood House. Staff told us these were well used during the summer. Care Homes for Older People Page 21 of 31 Evidence: During our visit part of the communal lounge in Glen Rosa was being redecorated. One person told us how the handyman was a saint and would decorate their room when asked. However three people did tell us their concerns about the new dining room furniture at Glen Rosa. They found the tables were too small to seat four people comfortably or for people who use wheelchairs and the chairs were too high, too narrow and uncomfortable. The registered manager told us she had received complaints about the furniture and this was being addressed by the home. To help prevent the spread of infections and to make the home a clean and comfortable place to live the home employ a cleaning team is employed. Anti-Bac soap dispensers are installed at wash-points and staff are instructed to adhere to the infection control policies and procedures. Care Homes for Older People Page 22 of 31 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Further improvements need to be made so people can be confident there are sufficient skilled staff to meet all their needs fully. Evidence: The registered manager and the staff told us there are normally three care staff working in Kitwood House for fourteen people and three in Glen Rosa and a senior carer who is in overall charge. The registered manager explained that they are trying to recruit a activities co-ordinator. There were many mixed comment made by people about the staff. Examples of these were:We have been impressed by the caring and dignified way residents are treated. My relative thinks the staff are very nice. Some of the seniors are very good, but have had a difficult time in regards to staff with different skills and experience, staff have not being staying very long and the good ones leave. The staff have all different personalities and some dont want to learn. Care Homes for Older People Page 23 of 31 Evidence: Some staff are respectful other are not, some are skilled and experienced others are not. Definitely short of staff. When we asked in the survey do the staff listen and act on what you say the comments made were:Sometimes they listen now and again they dont. Staff perhaps listen but very often there is no action. There is a lot of forgetfulness. Also when we asked is there enough staff two said they always was and three said there usually was enough staff. A comment made was:This depends on what is happening at the specific time. Those who are very dependent have priority but all residents have needs and some, I feel rightly so dont get what they should. The staff told us that people now needed more help so they found meeting all of peoples needs difficult. Overall the comments made by staff and people living in the home showed us that there are not enough staff to meet all of peoples needs especially for social activities. Four people and two staff also commented upon the difficulties of both working with and being cared by staff whose first language was not English. The registered manager showed us as part of her action plan she has recognised the difficulty for people where English is not the first language and is now ensuring efforts are made to make sure staff are able to fully understand peoples needs. We looked at three staff records all to make sure the home were employing suitable people for the job. Although the home had completed all the necessary recruitment checks to make sure only suitable staff were employed, we found the home had obtained copies of references rather than original documents. Where possible the registered manager should do all possible to make sure the references are authentic and appropriate. The registered manager explained there is a induction programme in place that ensures new staff members are given the right information to be able to do their jobs well. A member of staff described how they had completed computer based training and been supervised by one of the senior staff. Care Homes for Older People Page 24 of 31 Evidence: Staff told us they had received regular training and felt they had received enough training to enable them to carry out their jobs properly. The registered manager told us that training on the mental capacity act is planned for 2009 and most staff have received training about how to care for a person with dementia. The registered manager provided us with information which showed us under half of the staff have completed their National Vocational Qualification level two or above in care. This qualification helps staff to look after people properly. From the comments received the registered manager needs to enable more staff to complete this training so people can be more confident about the care they are receiving. Staff confirmed they have regular meetings and the registered manager explained these are used as a opportunity to recap policies and to make sure staff are kept up to date and able to carry out their roles properly. Care Homes for Older People Page 25 of 31 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 registered manager is now working towards making sure the home is managed in peoples best interests. Evidence: The home is owned by Methodist Homes Association. A not for profit organisation. Although founded on Methodist values, the home welcomes both residents and staff from different cultures and religions, and has successfully created a culture of respect for the individual. The manager, Mrs S Sullivan, has many years experience working for the organisation, and has completed an academic management qualification the Registered Managers Award. The registered manager explained that she had been working at a different home for six weeks and had recently returned to Glen Rosa and Kitwood House. This inspection has shown us that the home has had some problems with staff Care Homes for Older People Page 26 of 31 Evidence: recruitment in 2008 which has affected the service which people receive. However following the recent annual survey the registered manager is now aware of the issues and feelings this has raised and has put into place a plan that should resolve most of the issues. Quality assurance systems consisted of an annual survey for people in the home to complete, regular house meetings, care reviews, and reviews of the complaints and accidents records to identify any patterns etc. The registered manager had recently completed a residents satisfaction survey and the results had been quite negative. She was able to show us an action plan about how she is responding to the negative comments made. People also told us they were able to make their views known through a residents committee. The administrator explained where residents wish the home to keep money for them, all transactions are recorded, and receipts are kept and held separately in a locked safe. Staff told us they have generally received regular supervision and appraisals from their manager. The fire procedure is displayed throughout the home and fire detection and firefighting equipment is tested and maintained regularly. The registered manager told us the annual checks for health and safety are in place. The maintenance man is responsible for the checking of all health and safety documents. The registered manager also sent us information to show the maintenance records are up to date. Care Homes for Older People Page 27 of 31 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 31 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 9 13 Medication sheets must always be signed when medication is given. This is to prevent any mistakes being made. 27/02/2009 2 12 16 You must carry out a review of everyones daily life and activities to make sure any activities are tailored to reflect peoples individual needs and provide these activities. This will provide people with a fuller and more active lifestyle of their choice. 02/03/2009 3 27 18 Staffing levels must be 27/02/2009 reviewed and where necessary increased to make sure that there are sufficient staff on duty at all times to meet everyones needs. This is to make sure all of peoples needs are met. Care Homes for Older People Page 29 of 31 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 Care plans and risk assessments need to be up to date, person centred and reflect the help and support people need. Care Homes for Older People Page 30 of 31 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. 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