Inspection on 22/07/09 for Hazelgrove Court Nursing Home

This inspection was carried out on 22nd July 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hazelgrove Court Nursing Home 01/10/07

Hazelgrove Court Nursing Home 26/09/06

Hazelgrove Court Nursing Home 28/11/05

Hazelgrove Court Nursing Home 10/05/05

Hazelgrove Court Nursing Home 22/02/05

Hazelgrove Court Nursing Home 22/06/04

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 16/02/2010.

Key inspection report Care homes for older people Name: Address: Hazelgrove Court Nursing Home Randolph Street Saltburn-by-Sea TS12 1LN     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Katherine Acheson     Date: 2 2 0 7 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. 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. Care Homes for Older People Page 2 of 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Hazelgrove Court Nursing Home Randolph Street Saltburn-by-Sea TS12 1LN 01287625800 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): hazelgrovecourt@new-meronden.co.uk Premier Nursing Homes Limited Name of registered manager (if applicable) Mr Damian Bernard Hunt Type of registration: Number of places registered: care home 48 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: Manager (Mrs Lesley Smith) to attain the `Caring for people with Dementia` course or equivalent within 1 year of registration. The Manager (Mrs Lesley Smith) should attain a relevant Management qualification by 2005. To allow the admission of one named individual who is under the age category to reside in the home. To allow the admission of upto 3 people with a Physical Disability (PD) aged 55 years plus. To allow the admission of upto 3 people with Dementia aged 55 years plus. Date of last inspection Care Homes for Older People Page 4 of 29 Over 65 24 24 0 0 0 48 Brief description of the care home Hazlegrove is a 48-bedded care home providing both personal and nursing care. The home offers single room accommodation, which meets with the national minimum standards as to size. All rooms have en-suite toilet facilities, which consist of a toilet and hand wash basin. The home is operated as two specific units; on the ground floor the home provides care for 24 older people with physical disabilities; on the first floor care is provided for 24 older people with dementia. Each unit has two lounges and a dining room. Toilet and bathing facilities are available on each unit. The home is situated in Saltburn close to the town centre and sea front; it is close to local shops and amenities. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The Quality rating for this service is two star. This means that people who use the service experience good quality outcomes. We have reviewed our practice when making requirements to improve national consistency. Some regulations from previous inspections 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 risk or harm. In future if a requirement is repeated it is likely that enforcement action will be taken. Two regulation inspectors carried out this unannounced key inspection on the 22nd July 2009. The reason for the inspection was to see how good a job the home does in meeting the national minimum standards set by the Government for care homes. Care Homes for Older People Page 6 of 29 Numerous records were examined including care records of people living at the home, medication records, risk assessments, complaints and staff records. People living the home, relatives and staff working there were spoken to. Discussions took place with the manager and the homes area manager. Before the inspection surveys for people that use the service, relatives and staff were sent to the home for the manager to distribute accordingly. Surveys sent to people that use the service and relatives were asked to comment on care received. Surveys sent to staff were asked to comment on what it was like working at the home and training. We received eleven surveys from people that use the service and four from relatives. We did not receive any completed surveys from staff. The cost of care at the time of the inspection visit ranged from four hundred and fifty eight pounds and ninety pence to five hundred and ninety five pounds and thirty eight pence a week. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: Care plans need further development to ensure that they are individual to the person. Care plans need to include limitations, abilities, preferences and assistance required. The homes complaint procedure should be updated to include contact details of funding authorities to ensure that people are aware of who they can make a complaint to. The homes adult protection procedure should be updated to include clear action for staff to follow if abuse is suspected. The procedure should be updated with contact Care Homes for Older People Page 8 of 29 numbers of Local Authorities to help to ensure that a prompt referral is made and that staff know who to contact if abuse is suspected. The homes recruitment procedure is not as robust as it should be, which does not help to ensure that people are protected. Records looked at during the inspection identified that Criminal Record Bureau checks are not always carried out on staff before they start working at the home. The employment history on some staff application forms detailed years worked from until and not date specific, which would enable the exploration of gaps in employment. 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 29 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 29 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. Assessments of people who are to use the service are carried out before they move into the home to ensure all needs can be met. Evidence: Before going into Hazelgrove Court people who are to use the service are assessed by a social worker or health care professional. This assessment is forwarded to the home for the manager to look at to determine if the needs of the person can be met. Once this assessment has been reviewed the manager said that he visits the person at home or in hospital to introduce himself, answer any questions about the home and carry out a further assessment on the person. If a person is funding their own care an assessment is usually only undertaken by the manager of the home. During the inspection four files of people that use the service were selected at Care Homes for Older People Page 11 of 29 Evidence: random. Files looked at did contain evidence of assessment. People who are to use the service and their relatives are welcome to visit the home, have a look round and meet the staff. Care Homes for Older People Page 12 of 29 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 who use the service are happy with the care that they receive. Care plans need further development to ensure that they are individual to the person to help to ensure that all aspects of health, personal and social care needs are met. Evidence: The files of four people that use the service were looked at during the visit, two from the dementia unit and two from the older persons unit. At the time of the inspection visit the home were in the process of changing to new care plan documentation. Files contained a detailed assessment of needs for the person, evidence of nutritional screening and moving and handling assessments. One plan of care looked at during the visit contained a questionnaire called residents choice. This contained detailed information about preferred meal times, food likes and dislikes, what time the person wanted to get up and go to bed and if they preferred a male or female care staff member to assist with their care needs. Following assessment a plan of care is developed. Care plans examined during the Care Homes for Older People Page 13 of 29 Evidence: visit were not specific to the person or include enough information. An example of this being, one person was identified as being aggressive on intervention, however this plan of care did not detail what intervention made the person aggressive, if there were any triggers to the aggressiveness or detail what staff should do to manage the problem. Another plan of care looked at during the visit identified that a person needed help with personal hygiene and stated, Two carers to ensure his/her hygiene needs are met and ensure he/she wears appropriate clothes. This plan of care should be developed to state what the person can do for themselves and what help they need. The plan of care should include if any equipment is needed, evidence of personal choice and preference and identify if there are any risks associated with the task. Care plans looked at were evaluated on a monthly basis or more often if needed. There is clear evidence of the involvement of GPs, District Nurses and other healthcare professionals such as chiropodists. People spoken to during the visit and surveys received in were complimentary about life in the home and care received. Comments made included, The home is very good, communication is good and physical needs are well met The home and staff are wonderful we couldnt manage without it It is perfect We are really happy with the care and support given to dad and the extended family The staff bothered to find out the little things, they asked if he/she preferred a duvet or blankets, how many pillows he/she liked. Staff asked about likes and dislikes We are happy this is the best move we have made. We are better off Indirect observation showed that staff were respectful and attentive when attending to people that use the service. During the inspection a discussion took place with a care staff member who advised that she now acts as a dignity adviser. This care staff member advised said that she is an advocate for people and that her role was to ensure that staff respect peoples dignity and privacy. The staff member said that she observes staff at work and identifies good and not so good practice and then speaks to staff about this. Care Homes for Older People Page 14 of 29 Evidence: During the inspection arrangements for receiving, storing, administering, recording and disposing of medication were observed and examined on the older persons unit. Record keeping was good and medicines were appropriately stored. The manager said that nurses working at the home give out medication to people who use the service. Care Homes for Older People Page 15 of 29 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 that use the service lead fulfilling lifestyles through exercising choice and control over how they spend their day. Food provided is enjoyed by people that use the service. Evidence: The manager said that the home employs an activity co-ordinator to plan, arrange and take part in activities for people that use the service. The activity co-ordinator works twenty hours a week, Monday to Friday. Activities taking place on a daily basis include bingo, quizzes, movement to music, pamper sessions and craft. People spoken to during the visit thought very highly of the activity co-ordinator. On the afternoon of the inspection a singer had been booked to come in and entertain people. Other recent activities and events that have taken place have included, a visit from Kirkleatham museum, an afternoon of entertainment from a vocalist/guitarist, an afternoon with domestic and exotic pets. The home have just had a summer fete. A P.A.T dog visits the home on a regular basis. The Labrador named as Kepp is obviously a firm favourite of people who use the service. A P.A.T dog is a therapy Care Homes for Older People Page 16 of 29 Evidence: visiting dog that is said to give a powerful aid to stimulation and offer companionship. The dog gives people a point of communication and physical contact with a pet. The manager of the home with the help of staff, relatives and people who use the service created a fabulous corridor display of second world war memorabilia. Comments made by people spoken to during the inspection and surveys received in respect of activities and outings included, I have just started knitting, but nothing too elaborate I like the bingo, we all have fun. The summer fete was good, but we had to do it inside because of the great British weather The staff are great, we have fun, happy times The activity co-ordinator is great. She works really hard to keep us entertained We have pamper sessions we have nail varnish put on I helped to do the 1940s display, it was great fun and brought back lots of memories One person who uses the service showed the Inspector the monthly plan of activities that had been given to him. This person said, There is always something to do. The manager said that people that use the service are supported and encouraged to practice their religion. He said that one person goes to church with family on a regular basis and that the home are to host a second non denominational gathering on 12th August 2009. The manager advised that the home have just developed a remembrance book, which contains pictures and messages of people who have used the service and have died in the last twelve months. A Forget me not service is to be held in October to remember people. Family, friends, staff and people who use the service are to be invited. Visitors are welcome at any time and are welcome to stay for a meal. The home has a welcoming atmosphere and on the day of the inspection there was a plentiful supply of visitor and activity. Comments made by relatives and visitors on the day of the Care Homes for Older People Page 17 of 29 Evidence: inspection and in surveys received included, The home encourages the family to be involved in the care and day to day support of dad We were welcomed by every member of staff we met. This has continued and we are included in the daily life of the nursing home I visit every day and always feel welcome. There is always a cup of tea and I can stay for a meal if I want. Food provided by the home is enjoyed by people who use the service. The lunch time of people on the dementia unit was observed. The lunch time menu of the day was beef and mushroom casserole, creamed potato, cabbage and turnip or roast pork, potatoes and vegetables. For desert it was rhubarb crumble. The home has a four week menu plan which offers a choice at each meal time. The lunchtime of people on the dementia unit was relaxed with people enjoying the food that was provided. Staff were assisting those people that need help at meal time. The manager said that on both the older persons unit and dementia unit there are two sittings to make sure that meal time is relaxed and so that people get the support that they need. People spoken to during the inspection and surveys received spoke highly of the food provided comments made included, Before we came in here we lived on frozen dinners. The food is great, anything we want, plenty of it and nice and fresh The food is lovely We have lots of choice, last night I didnt want the sausage roll for tea, I asked for cheese on toast and like magic it was there. Care Homes for Older People Page 18 of 29 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 confident that their complaints would be listened to, taken seriously and acted upon. Adult protection procedures do not include clear action for staff to follow if abuse is suspected, which could compromise the safety of people who use the service. Evidence: The home has a complaints procedure, which details how to make a complaint, who to contact and timescales for action. This procedure needs to be updated to inform people of their rights to contact funding authorities. People spoken to during the visit said that they would feel comfortable and confident in raising any concern that they may have with the manager of the home. There have been four complaints in the last twelve months. The home has an adult protection procedure for staff to follow, however this is confusing. The Procedure needs to be updated to ensure that in the first instance any allegation of abuse should be reported to the Local Authority prior to any investigation taking place. The procedure would benefit from being updated to inform of Local Authority telephone numbers to help to ensure that staff know who to contact if abuse is suspected. Records were available to confirm that staff have received recent training on adult protection. Care Homes for Older People Page 19 of 29 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 standard of the environment is good providing people that live there with an attractive, homely and comfortable place to live. Risk assessing needs to take place of the antibacterial hand gel dispensers to help to ensure the safety of people that use the service. Evidence: Hazelgrove Court is a care home providing both personal and nursing care to a maximum number of forty eight people. The home has two units. Swaledale unit is on the ground floor of the home and can accommodate a maximum number of twenty four older people requiring personal and nursing care. Rosedale unit on the first floor of the home can accommodate a maximum number of twenty four people with dementia who require personal and nursing care. All bedrooms in the home are single and offer ensuite facilities of a toilet and sink. Each unit has communal lounge and dining areas. The home is close to the Saltburn town centre and sea front. The Inspector walked around the home with the manager. Communal areas were well maintained with good quality furniture. Bedrooms of people that use the service that were looked were nicely decorated, had appropriate furniture and were personalised. Care Homes for Older People Page 20 of 29 Evidence: Since last inspection a ground floor corridor area of the home has been developed to create a fabulous display of second world war memorabilia. Some bathrooms areas have benefited from redecoration. Bedroom doors on the first floor of the home were locked. The manager advised that this was mostly at the request of families to prevent other people with dementia wandering into bedrooms that were not their own. People are able to access the bedrooms if they ask, however it was recognised that most people who resided on the dementia unit would not ask. The manager advised that he has plans to develop the first floor of the home and that one idea is to put pictures and memorabilia on or outside the bedroom door to help people to identify their room, which would then mean that doors could be unlocked. There is a pleasant enclosed garden area for people who use the service. Appropriate laundry facilities are in place. Staff said that there was a plentiful supply of protective clothing. On the day of the inspection the home was clean and odour free. Some care staff working at the home have been appointed as infection control advisors. A care staff member spoken to during the visit advised that she had received excellent infection control training which has assisted her with her role. It was noted that hand dispensers containing antibacterial hand gel had been fitted to a number of areas of the home. There were a number of hand gel dispensers fitted to the main corridor area on the dementia unit. The manager and staff were asked about ensuring safety of people on the dementia unit and if any people were likely to put the gel into their mouth. The manager advised that they had not thought about the possibility of people putting the gel in their mouth or what COSHH or safety procedures should be in place if this was to happen. The manager advised that dispensers had been placed in corridor areas for infection control, however feels that in the interest of safety hand dispensers should be removed from areas accessible to people who use the service on the dementia unit. Care Homes for Older People Page 21 of 29 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. Mandatory training and other training relevant to the job staff do is provided ensuring that staff are knowledgeable and experienced to meet the needs of people using the service. The homes recruitment procedure is not as robust as it should be, which does not help to ensure that people are protected. Evidence: At the time of the inspection there were forty four people using the service, Swaledale, the older persons unit on the ground floor of the home had an occupancy of twenty two people. Duty rotas looked at during the visit advised that there are four care staff on duty in a morning and three care staff on duty during the afternoon and evening. A nurse is also on duty during the morning, afternoon and evening. Rosedale, the unit on the first floor of the home that cares for people with dementia also had an occupancy of twenty two people. Duty rotas looked at during the visit informed that there are four care staff on duty in a morning, three care staff on duty during the afternoon and either three or four care staff on duty on an evening. A nurse is also on duty during the morning, afternoon and evening. On night duty there are two nurses and three care assistants on duty. The manager advised that there is a nurse and care assistant on each unit with the other care assistant spending time between both units. Care Homes for Older People Page 22 of 29 Evidence: The manager of the home works full time and is supernumerary. The manager said that ninety four percent of care staff working at the home had achieved a minimum qualification of NVQ level 2 in Care. Records looked at during the inspection identified that the homes recruitment procedure is not as robust as it should be. One staff file looked at during the visit was that of a care staff member who started working at the home in September 2008. References had been obtained prior to commencement of employment, however a Criminal Record Bureau check had not. It was also noted that the employment history on the application form was incomplete and only contained the year worked from until the year work to. Application forms should be date specific to enable the exploration of any gaps in employment. Another file looked at was that of a staff member who had started working at the home in January 2009. References had been obtained prior to the commencement of employment and a POVA first check had been undertaken, however the manager was unable to locate the Criminal Record Bureau check at the time of the inspection, The manager advised in a telephone call after the inspection that he had managed to find the confirmation that a Criminal Record Bureau check had been undertaken prior to commencement of employment. Records were available to confirm that new staff receive induction training. Staff files examined during the visit contained certificates to confirm that staff had recently attended training in Moving and handling, fire, adult protection, first aid, infection control and health and safety. Care Homes for Older People Page 23 of 29 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 well managed and run in the interest of people that use the service. The health, safety and welfare of people that use the service is promoted. Evidence: Since last inspection of the service a new manager has been appointed. The manager is a Registered General Nurse who has just completed a management qualification. At the time of the inspection the manager had made an application for registration as manager with the Care Quality Commission and was going through the fit person process. People who use the service, relatives and staff spoke positively about the new manager comments made included, The home has transformed since the new manager, everything is much better and, The manager is very approachable. We have a good staff team. Appropriate quality assurance monitoring systems are in place. Surveys are sent out to people that use the service on a regular basis to make sure that they are happy with the home and the care that they receive. Surveys were last sent out in February Care Homes for Older People Page 24 of 29 Evidence: 2009 a report was available that summarised the findings. The home does not look after personal money for people that use the service. If money is required the home will pay and then an invoice will be sent to the person or next of kin. A sample of health and safety records were examined and in general found to be in order. Records were available to confirm that the homes fire alarm, fire extinguishers, portable appliance testing and gas boilers had been serviced in the last twelve months. Records examined confirmed that tests of the fire alarm system take place on a weekly basis and that water temperatures are taken of sinks on a monthly basis and baths and showers on a weekly basis. Care Homes for Older People Page 25 of 29 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 29 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 26 13 The registered person must 22/07/2009 carry out a risk assessment to determine if it is safe for antibacterial hand gel dispensers to be in areas accessible to people who use the service. This will help to ensure that all parts of the care home to which people have access are so far as reasonably practicable free from hazards to their safety. The registered person must ensure that Criminal Record Bureau checks are carried out on all new staff prior to the commencement of employment. This will help to ensure that people are protected. 22/07/2009 2 29 19 Care Homes for Older People Page 27 of 29 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 The Registered Person should ensure that care plans are developed further to ensure that they are individual to the person. Care plans need to include limitations, abilities, preferences and assistance required. The homes complaint procedure should be updated to include contact details of funding authorities to ensure that people are aware of who they can make a complaint to. The homes adult protection procedure should be updated to include clear action for staff to following if abuse is suspected. The procedure should be updated to include contact numbers of Local Authorities to help to ensure that a prompt referral is made and that staff know who to contact if abuse is suspected. The registered person should ensure that application forms are completed with date specific entries for employment to enable the exploration of gaps in employment. 2 16 3 18 4 29 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!