Inspection on 20/01/09 for Hadleigh House Care Home

This inspection was carried out on 20th January 2009.

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

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

Other inspections for this house

Hadleigh House Care Home 13/10/08

Hadleigh House Care Home 05/02/08

Hadleigh House Care Home 13/03/07

Hadleigh House Care Home 14/02/06

Hadleigh House Care Home 04/10/05

Hadleigh House Care Home 18/11/04

Hadleigh House Care Home 16/07/04

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: Hadleigh House Care Home 350 Pelham Road Immingham North East Lincs DN40 1PU     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: Jane Lyons     Date: 2 0 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 28 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 28 Information about the care home Name of care home: Address: Hadleigh House Care Home 350 Pelham Road Immingham North East Lincs DN40 1PU 01469572514 01469573130 enquiries@hadleighcare.co.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) : Mr Michael Thomas Bailey care home 38 Number of places (if applicable): Under 65 Over 65 38 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home 0 Hadleigh House provides comfortable, homely accommodation for up to 38 people over the age of 65. The home is situated close to all amenities in Immingham. It has pleasant gardens; its own car park and is on a bus route. The home is a two-storey building with access to the first floor via stairs and a passenger lift, it is well maintained in terms of decor and furnishings. There are 32 single bedrooms and 3 shared, en-suite facilities are provided for the five new single bedrooms on the first floor. There are four bathrooms and a shower room with separate WC facilities provided on each floor. The home provides 3 lounges and a pleasant dining room for people to use. The rear garden has been landscaped and an attractive courtyard area provided, with seating and shade for individuals and their visitors. Ample car parking space is provided. The home is owned by Mr M Bailey. The Registered Manager is Marie Woodley. Weekly fees are between three hundred and sixty one pounds and four hundred pounds. The home operates a system whereby the fees include a third party contribution of fifteen pounds. Additional charges are made for the following: toiletries, newspapers/magazines, hairdressing, chiropody and escort fees. Information on the Care Homes for Older People Page 4 of 28 Brief description of the care home service is made available to prospective and current people who use the service via the statement of purpose, service user guide and inspection report. Documents are made available prior to and following admission, copies are available in the lounge area of the home. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) from the last twelve months including information gathered during a site visit to the home, which took approximately six hours. A random inspection of this service took place in October 2008 to check compliance with the requirements made at the last key inspection visit in February 2008. This was a very positive inspection and there was evidence that fifteen of the sixteen requirements made had been fully actioned. Reference to the random inspection visit is also made within this report. As part of the inspection process surveys were sent out to ten people who live in the Care Homes for Older People Page 6 of 28 home and ten staff who work there. Surveys were received from four individuals and four staff members. Comments were positive such as I find Hadleigh House provides everything I could wish for and I am very happy here all my needs are met. Anonymised comments from surveys and from discussions on the day of the site visit will be included throughout the report. Throughout the day we spoke to people who live in the home to gain a picture of what life is like at Hadleigh House. We also had discussions with the registered manager, the proprietor, care staff, the cook, four relatives and a visiting district nursing sister. We looked at assessments of need made before people were admitted to the home, and the homes care plans to see how those needs were to be met while they were living there. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff recruitment, staff training, how the home monitors the quality of service provided and how the home is managed overall. We also checked with people to make sure that privacy and dignity is maintained, that people can make choices about aspects of their lives and that the home ensures they are protected in a safe clean environment. We observed the way staff spoke to people and supported them and checked out with them their understanding of how to maintain privacy, dignity, independence and choice. We would like to thank the people who live in Hadleigh House, the staff team and management for their hospitality during the visit and also thank the people who spoke with us. 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 the 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? The management and staff have completed all the things they were asked to do at the last inspection visit. The manager has gained her registration and staff moral has continued to improve under her leadership. They have improved te care plans further to make them clearer for staff and ensure people at the home have contributed to them. Peoples health needs are better protected through safer management of the medication systems. Policies and procedures have been improved, administration records have improved, staff are monitored regularly in their practice by the manager and have enrolled on refresher training. One minor shortfall was noted in the standard of handwritten records which the manager confirmed she would address. People in the home have been consulted more about the services provided and have more opportunities to make suggestions. The quality assurance system has been broadened to include more audits and to obtain the views of visiting professionals and others. Care Homes for Older People Page 8 of 28 Staff have accessed more training, this gives them the expertise they need to support people living in the home. Better health and safety systems are in place that protect people and others from the risk of harm. Staffing levels have been reviewed and are being more closely monitored to ensure enough staff are provided to meet peoples health, personal and social needs effectively. 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 28 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are confident that the home can support them 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, what they hope for and what support they need. Evidence: We looked at a sample of files which belong to people who live at the home and we saw that these contain copies of assessments undertaken by the placing authority and the home. The assessments cover all aspects of health, personal care and social needs. In addition to this, information is also requested from the family, friends and health and social care professionals so that the home has as much information about the prospective individual prior to their admission. All of the information gathered at the time of admission is collated and used to develop an individual care plan for each person.People told us that they or their family had Care Homes for Older People Page 11 of 28 Evidence: visited the home to look round before they decided to move in and some people said that they had respite care at the home before they made a decision about moving in permanently. One person said The home is lovely,Im very happy here, I wish Id moved in years ago. The home does not provide intermediate care dedicated to accommodate individuals with intensive rehabilitation needs although feedback from health care professionals confirmed that the home has provided very good support in promoting independence for those individuals admitted for short term respite care to enable them to return to their homes. Care Homes for Older People Page 12 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive personal support from staff in the way they prefer and want. Their health needs are met because the home has procedures in place that staff follow.If people 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. Evidence: We carried out a random inspection of the home in October 2008 and this showed that the staff had made many improvements to the quality of the recording in the care plans and that the care plans were more detailed to direct staff on the actions they needed to take to meet the needs of the people they care for and were more person focused with more information about peoples abilities and personal preferences. At this visit we looked at care records for three people who have a range of needs and this showed that the standard of recording has been maintained, those examined were very thorough and detailed all the assessed needs. We saw that the care plans are updated regularly and any changes in the persons needs are well documented. Care Homes for Older People Page 13 of 28 Evidence: Risk assessments are completed for specific activities that the staff feel pose a risk to the individual.Those seen include nutrition, skin condition, mobility, evacuation in case of fire, use of bed rails, falls and specific health related issues. Daily recordings have improved and staff record how the individual has been throughout the day, the records mainly focus on how the health and personal care needs have been met and improvements could be made by including more information on how the individual has spent their day and what they have enjoyed doing. Care plans are regularly evaluated, they are audited by the manager and review meetings with families and representatives are held. There was evidence that people have access to health professionals and any contact and outcomes from discussions and visits are clearly documented. During the visit we spoke to a health care professional who regularly visits the home, she told us We are very pleased with the home, there have been many improvements and Marie the manager and the staff are very good.They carry out care well, inform us if peoples needs have changed or if they have concerns, we have a good rapport with all the staff team. We saw evidence that people are weighed on a regular basis, the chair scales are now checked to ensure accuracy. Pressure care and continence care is reviewed on a regular basis and any equipment needed is provided, there is evidence that advice is sought from others where necessary.All people spoken to confirmed that they receive the medical support they need. At the random inspection in October, there was evidence that the home had made improvements to ensure that the safety of people living in the home was more fully protected and appropriate action taken following accidents in the home. At this visit we looked at accident record audits which showed that there had been a reduction in the number of falls in the home over the last few months. Accident records were completed appropriately by staff with evidence that follow up action was taken where necessary. People spoken with stated that their needs are met at the home and they are very satisfied with the support they receive, some of the comments included The staff are very good, they look after us very well,they have arranged for the doctor to come and see me today and I just need a bit of help in the mornings but the staff are always there if I need them. When we spoke with staff they were clear about how to maintain peoples dignity and uphold their rights.We saw that the staff were sensitive to peoples needs when undertaking any personal tasks and sensitive and patient when dealing with those people who have some memory loss problems. Pharmacy advisors from the local Care Trust Plus had visited the home in September to look into some issues raised as part of a complaints investigation, a number of Care Homes for Older People Page 14 of 28 Evidence: recommendations around the recording systems were made. The medication systems were looked at as part of the random inspection in October and this showed that improvements had been made to better ensure the safety of the people at the home and the majority of recommendations had been met. At this visit we again looked at how the home handles and stores medication. New medication policies and procedures have been put in place which are more detailed and cover all aspects of the medication system. The manager confirmed that the senior care staff were now enrolled to start a medication refresher course.There was evidence that the manager had completed at least four supervised medication rounds with each of the senior care staff to ensure they are competent in their administration and recording practices. The manager audits the medication records each week and carries out a full audit of all storage and medication records each month. There is good evidence that the staff check all medications received by the pharmacy and make sure that the correct medication has been delivered.The manager has made sure that the pharmacy has increased the number of printed medication administration records they provide to the home which means staff do not have to write so many records and this reduces the risk of errors. Records which have been written by staff were checked and this showed that two signatures were not always in place, which is a good practice recommendation to make sure the record has been witnessed as correct. Any prescription changes made by the doctor over the telephone are now clearly recorded and the home now makes sure that the doctor provides a new prescription via the fax machine, this ensures the systems are safer. The staff make sure the recording of the medication is up to date.Storage seen was managed satisfactorily. There are some opportunities to self medicate and one person said I take my own tablets regularly and staff check this and another person said I like the staff to look after my medicines, as I might forget to take them. Care Homes for Older People Page 15 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home have a good quality of life although in recent weeks there have been limited opportunities for some people to be involved in many social activities. Peoples nutritional needs are met with well prepared and presented meals. Evidence: When we spoke with people who live at the home they said they could make choices about activities, food, how to spend their time and when to get up and go to bed. One person said Life here is what you make it, I choose how I spend my time and the staff help me when I need them. The home encourages contact with relatives and friends, throughout the day we observed a number of visitors to the home and the positive rapport they have with staff. One person said I visit the home three or four times a week at different times, the staff are always very friendly and welcoming. I always take Mum out to Morrisons each Tuesday where we can have a coffee and do a bit of shopping which she enjoys. Many people told us how much they had enjoyed Christmas at the home, how nicely the home had been decorated, that the local school children had visited to sing Carols and there had been a trip out to a show. Care Homes for Older People Page 16 of 28 Evidence: The home employs an activity organiser who has been on leave from the home since November, there was evidence from records and discussions with people and their relatives that the amount of activities provided in the home since that time has tailed off. One person said Mum is really settled and happy at the home but she misses the activity organiser and it would be nice if they did a bit more. Other people told us Staff do some activities with us but Im not really fussed, I like to sit and chat with the other ladies and Staff spend time sitting and chatting to us which I like, they do our nails sometimes and I like the Bingo. The manager confirmed that they had recruited a new activity organiser to provide support for the home however she was unsure when the person could start work. In the meantime the manager was planning to give some extra hours to a number of care staff who had shown interest in organising the activities and entertainment in the home. The meals provided looked well prepared and presented. People spoken with stated they liked the food and had plenty to eat and drink. Comments from people included The meals are always excellent,at lunch we always get three vegetables and thats not including the potatoes and we are well fed, the meals are lovely and there is a good variety. There was evidence that the menu is reviewed regularly and people are consulted about new menu changes and particular preferences. The home caters for special diets and dietetic advice is obtained where required. Care Homes for Older People Page 17 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides an environment where people feel able to complain and express their views. People who use the service are protected from abuse by the staffs awareness of policies and procedures and completion of appropriate training. Evidence: The home has a policy and procedure to deal any complaints which is displayed in the hall. People spoken with felt able to complain if they needed to and most mentioned the manager or one of the senior care staff by name as the person they would speak to if they were unhappy about something. Staff were also aware of what to do if an individual or visitor raised any concerns with them. Checks on complaint records show that improvements have been made to the standard of complaints investigation and recording of outcomes. The complaints department of the local Care Trust Plus told us earlier in the year that the home had worked very positively with them during a complaints investigation. This department have offered their continued support to the homes management to oversee future handling of complaints. The CSCI have not received any complaints since the last key inspection. The home follows the local Care Trust Plus multi- agency policy and procedure for safeguarding adults from abuse.Records show that all existing staff have accessed this course and training has been arranged for newly recruited staff to attend in January and February. Staff spoken with confirmed that training had taken place and knew Care Homes for Older People Page 18 of 28 Evidence: what to do if they witnessed anything that concerns them. The home has not been subject to any safeguarding referrals or investigations since the last key inspection. Care Homes for Older People Page 19 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People feel at home at Hadleigh House, they are provided with a warm and comfortable environment suitable to their needs. Evidence: The home provides and maintains very comfortable facilities; there is a rolling programme of redecoration carried out. The ground floor corridor carpets are currently being replaced. The home benefits from having a number of lounges in which the people who use the service can choose to socialise, or have some private time in, we observed people spending time in the different rooms throughout the visit. The toilets and bathrooms are all close to the communal and bedroom areas. People who use the service told us how happy and settled they are at the home. All areas of the home were very clean and tidy, people spoken to told us that the home was always kept clean and smelt fresh. During a short tour of the home it was noted that there was a malodour in one of the bedrooms; the manager confirmed that she would look into the continence management for the individual. Staff confirmed in discussions that there were adequate supplies of protective clothing. Care Homes for Older People Page 20 of 28 Evidence: Positive comments were received during the visit regarding the facilities from visitors and people who use the service, these included Ive had the same bedroom for fourteen years, its just how I like it, Im very comfortable and happy here , and The home is lovely and clean, its close to my family so they can visit me regularly and Mums room is immaculate. Staff told us they had enough equipment to safely carry out their roles. The gardens are attractive and well maintained. There is ample parking for visitors. Care Homes for Older People Page 21 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People 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 ensure they are suitable. Peoples needs are met and they are supported because staff get the right training and support from their managers. Evidence: At the random inspection in October 2008 a requirement was made to ensure that appropriate numbers of staff were rostered to meet the dependency needs of the people who use the service. A shortfall of hours was identified on the roster from the staffing hours calculated in line with The Residential Staffing Forum, a dependency tool which provides the number of hours needed from the dependency needs of each individual. Evidence from this visit was that there were sufficient numbers of staff rostered to meet peoples needs, staff told us that they had enough time to carry out their tasks and spend time with people, this was observed during the visit. Staff had told us at the last visit how they had felt overstretched and that they had to rush to finish all their tasks, this has now settled completely which is due in the main to a reduction in occupancy levels. The manager confirmed that staffing hours had been reduced in recent weeks in line with the RHF dependency calculations, records confirmed this. Care Homes for Older People Page 22 of 28 Evidence: All people spoken with were very complimentary about the staff and they said that staff were always available when needed, comments included The staff here are wonderful, they are so patient and kind and They all know what I need help with and how I like things done and The staff are marvellous, cant do enough for you. New staff complete an in- house induction programme. Following this, they complete the Skills for Care common induction standards to assess their competence which is signed off by the manager on completion. Information provided by the manager before the visit shows that the home has achieved the target of having 50 of care staff qualified at NVQ in care at level 2 or 3. The remainder of staff are either working towards qualification or are due to start the course in January. We looked at the training matrix and some individual training records which indicates that members of staff have access to a range of mandatory, general and service specific courses. Training consists of in- house videos, distance learning and access to courses provided by the local CTP. The staff are now paid to attend the mandatory courses and the manager told us that the staff in general were now much keener to access training courses. Records show that staff were up to date with mandatory courses such as moving and handling, first aid and basic food hygiene. All the existing staff had received fire safety training in December 2007, and they now require an update, the manager confirmed that this training had now been arranged for February for all the staff. Over the last twelve months staff have accessed training in areas such as infection control, safeguarding adults, risk assessment, Diabetes, Dementia, Strokes and medication . The manager has arranged many courses for staff to attend over the next three months. When we spoke to staff they said they found the training very good and were pleased that the owner and manager encouraged them to attend more courses. They felt this gave them the skills needed to care for the people who live at the home. The recruitment and selection procedures are robust and all checks are undertaken prior to staff commencing work at the home. The staff files looked at contained references from previous employer, an application form which identified any gaps in employment and a completed Criminal Record Bureau(CRB) check. The home has supervision arrangements in place for those staff who work at the home under a POVA check until a full CRB check comes through. Care Homes for Older People Page 23 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is better managed and the health, safety and welfare of people who use the service and others is protected by the systems in place, including more effective quality assurance systems. Evidence: The manager of the home, Marie Woodley gained her registration with the commission in August 2008. She has recently completed her NVQ level 4 in care and has enrolled on a degree course in Leadership and Management which incorporates the Registered Managers Award. She also attends regular training courses and safe practice updates. When we spoke with people who live at the home they said the manager is very approachable and takes time to listen to them. Staff told us that moral had improved significantly since Marie had been running the home and that she had worked hard to make lots of improvements. Comments included Marie has made a real change to the home, she manages it well and its a lovely place to work now and our home is organised very well and we have a good team. Care Homes for Older People Page 24 of 28 Evidence: A random inspection visit was carried out in October 2008 to look at compliance towards the requirements made at the previous key inspection, the findings from that visit were very positive, with improvements made towards most of the management and administration systems in the home and there was evidence that fifteen of the sixteen requirements had been fully actioned. At this inspection there was evidence that some areas of improvement had been further embedded with more development of areas such as staff training and care documentation. The home now has a more developed quality assurance system in place that involves people who live in the home, carers, family, staff and other professionals such as doctors and district nurses, giving their views about the home. The manager carries out regular audits of key areas and there is good evidence that the inclusion of care plans and medication recording within this aspect of the programme has made significant improvements to those areas. Surveys are completed throughout the year, the findings are analysed by the manager and action plans drawn up where necessary, results of surveys seen during the visit show that people who use the service and their families are very satisfied with the services provided.Regular staff meetings and resident/ relative meetings are now held. The manager has reviewed and updated all policies and procedures for the home. A development plan has been produced however this is brief and the manager needs to produce a more detailed report which better describes the improvements and changes made from all the consultation with people and the direction the service is going and the improvements the home is planning to make over the next twelve months. Peoples finances are managed well. Individual records are maintained for monies held in safekeeping and receipts obtained for expenditures. The home is a safe place to live and work in. Appropriate risk assessments have been completed, equipment is in place and serviced regularly, fire alarm tests and drills are carried out, repairs completed quickly and the environment checked during audits. Staff receive training in infection control, fire safety, first aid and health and safety. Improvements have been made towards the management of bed rail provision in the home, risk assessments are more detailed and cover all areas identified in guidance issued from the Medical Advices Agency, records were seen which shows that staff make regular checks of this equipment. Care Homes for Older People Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 9 Where staff are handwriting the medication records (transcribing) a second staff member should witness the recording and sign the record as correct. This reduces the risk of error and better ensures peoples health. The full programme of activities and social support in the home should be restarted and maintained. A more detailed annual development plan should be produced which better describes the improvements and changes made from all the consultation with people, the direction the service is going and the improvements the home is planning to make over the next twelve months. 2 3 12 33 Care Homes for Older People Page 27 of 28 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (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. 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