Inspection on 05/11/08 for Hillingdon House

This inspection was carried out on 5th November 2008.

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

Hillingdon House 02/07/07

Hillingdon House 10/10/06

Hillingdon House 30/01/06

Hillingdon House 18/02/05

Hillingdon House 15/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 31/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Hillingdon House 170-172 Ashby Road Burton On Trent Staffordshire DE15 0LG     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: Yvonne Allen     Date: 0 5 1 1 2 0 0 8 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 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) 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 29 Information about the care home Name of care home: Address: Hillingdon House 170-172 Ashby Road Burton On Trent Staffordshire DE15 0LG 01283510274 F/P01283510274 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Jean Ann Miles Type of registration: Number of places registered: Miss Joanne Louise Miles,Mrs Jean Ann Miles care home 21 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: 1 PD minimum age 60 yrs Date of last inspection Brief description of the care home Hillingdon House is a residential care home offering 21 places for older people; it is not registered to support people with dementia. At the time of this inspection there were people who use the service with a dementia; their needs were met in the older persons category. The home has a registration to accommodate one person under 65 with a physical disability. Hillingdon House consists of two neighbouring Victorian properties; one houses 14 residents, the other 7. It is situated in a residential area of Burtonupon-Trent, affording residents the opportunity of maintaining links with the neighbouring community. It is well placed for the town centre and has the facility of a main bus route. Both the exteriors and the interiors of the properties are well maintained; they are both very clean and the decor is set to a good standard. People Care Homes for Older People Page 4 of 29 Over 65 21 0 Brief description of the care home are offered easy access to all areas of the home by the use of grab rails and a lift. All bedrooms meet the required sizes set out by the national minimum standards and are equipped with suitable fixtures and fittings. The bathrooms and toilets are well located and offer appropriate equipment and facilities. Communal areas are spacious and comfortable; patio areas with seating are available and easily accessed. From the information provided on the day of the inspection the current fees were 280 - 355 pounds, there would be additional cost for personal toiletries, hairdressing and any periodicals/newspapers and private chiropody. Mrs Jean Miles is the registered manager and the provider. 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 2 stars. This means that the people who use this service experience GOOD quality outcomes. Prior to the inspection visit the Provider had completed a self-assessment tool, which is known as the Annual Quality Assurance Assessment (AQAA). Completion of the AQAA is a legal requirement and it enables the service to undertake a self-assessment, which focuses on how well outcomes are met for people using the service. This was completed to a good standard and gave detailed information about the services offered. All of the Key minimum standards were assessed and for each outcome we have made Care Homes for Older People Page 6 of 29 a judgment, based on the evidence gathered. These judgments tell us what it is like for the people who live in this home. The ways in which we gathered evidence were as follows - Prior to the inspection visit we sent out and received back a number of surveys to people who live in the home, their relatives, and staff who work in the home. Their comments have been referred to throughout this report. We walked around the home and visited most of the bedrooms, the communal rooms, the kitchen and laundry. We spoke with the visitors who we met at the home. We spoke with a number of people who live in the home. We interviewed the staff members on duty at the home. We observed the interaction of staff with the people who live at the home, and looked at care practices. We examined relevant records and documentation. We case tracked 3 of the people who live in the home. This means that we looked at the care plans of these people and then observed the care they received throughout the visit. When we finished our inspection visit we gave verbal feedback to the deputy manager of the home as the manager was not on duty at the time. We spoke with the manager over the telephone after the inspection visit. This was a positive inspection and as a result we have not made any requirements but we have made a number of good practice recommendations for improvement. What the care home does well: What has improved since the last inspection? The previous requirements have been met in respect of developing risk assessments for the building, complying with the recommendations of the fire safety officer and recording hot water temperatures. This has helped to enusure the on going safety of the people who live in the home. Other improvements include - The development of new care plans and a Key Worker system, thus ensuring that care is planned and needs are met accordingly. Improvement in the staff team, thus helping to ensure that staff numbers and skill mix are better able to meet the needs of people living in the home. A new activities programme implemented thus helping to meet the social and therapeutic needs of peopl living in the home. A new visiting policy has been introduced - enabling visitors to see their relatives in private. A new menu has been developed with the input of people who live in the home. Thus helping to ensure that people are served meals of their choosing. The development of policies and procedures around standard 18 (safeguarding) has been improved, thus helping to ensure that people who live in the home are kept safe. The refurbishing and redecorating programme has included several bedrooms, replacing furniture and carpets. This has helped to improve the appearance of the environment for the people who live in the home. A new policy has been introduced for hand washing. This will help to ensure that infection control requirments are adhered to by the staff who work in the home. Care Homes for Older People Page 8 of 29 The staff recruitment procedure has been improved, thus helping to ensure that the right staff are carefully selected to work at the home. Improvements made to the staff training and development programme, have helped to ensure that staff are trained and have the skills to be able to meet the needs of the poeple who live in the home. 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 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. People have their individual needs assessed prior to being offered a place at the home and can be sure that the home will be able to meet these needs. Evidence: In their AQAA the providers tells us - We always make sure that a needs assessment has been carried out before offering a place at Hillingdon House, taking into account existing residents who live here. They say evidence for this is contained in, care plans, needs assessment forms and reviews, and, social services also provide us with the necessary care plans. During the course of the inspection the above information was found to be correct as highlighted below. It was identified that people are only offered a place at the home following an assessment of their needs. These pre admission assessments are usually carried out by the manager of the home. She goes out to assess people in their own home Care Homes for Older People Page 11 of 29 Evidence: environment, or hospital, or wherever they may be. We saw these assessments contained in three individual care plans we looked at and one person told us about her experience of an assessment prior to her coming into the home. She said, Jane came to see my at The Croft and thoroughly assessed me. We also noted that, where people are funded by Social Services, they have also had an assessment of their needs done by a Social Worker before coming into the home. These are contained in individual care plans. We were told by the Deputy Manager that places are only offered to people if the manager and staff are sure that the home can meet their individual needs. 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. Personal care is delivered with dignity and respect. People have a voice and personal preferences are upheld and health care needs are monitored with the assistance of health care professionals. Evidence: In their AQAA the Providers tell us - All residents have a personal care plan covering health and personal care. The manager tells us that the home, Encourage involvement of residents and their families in reviews of care plans. She also told us that, Care plans have improved, and there is a new Key Worker system in place. Throughout the inspection we found the above information to be a true reflection. We looked at a random selection of care plans. These were of a satisfactory standard and Daily Living Plansreflected the personal choices and preferences of people. People told us that they felt well cared for and were satisfied with the services provided for them at the home. One lady told us -I prefer to stay in my room and the Care Homes for Older People Page 13 of 29 Evidence: staff know that and, The routine is my routine and is based around what I want to do also, I have all my meals in my room and, I have plenty of visitors. There was a friend visiting at the time of the inspection visit who confirmed that her friend is, Very happy with the home. This persons care plan reflects her assessed needs and wishes and there are risk assessments in place. There was evidence of visits by health care professionals such as - GP, dentist, chiropodist and monthly reviews take place. It was identified that this person had not been weighed yet and has been in the home for 3 months. People should have their weight taken soon after admission to the home in order to provide a baseline for the monitoring of weight. Another care plan evidenced that this person is weighed 3 monthly. The person receives visits by the Chiropodist, the district nurse, the GP. The person has been receiving antibiotic therapy for a chest infection. It was noted that the Antibiotic Record Chart contained within the plan of care had not been completed. A Social Worker had reviewed this persons care recently. We spoke with the sister of another person accommodated in the home she is very happy with the home and care provided to her relative. She told us, My brothers needs are managed well by the staff in the home. Another person told us - The staff are very good and very patient with a resident who has dementia - they are lovely with him. We observed the carer administering the lunchtime medication. There is 1 person who is self administering her own medication and there is a risk assessment in place and her medication is locked up in her bedroom. Medication Administration Record charts are completed as required. All staff who administer medication have received certificated training - we saw these and staff spoken to confirmed this. We observed staff to be polite and respectful toward people using the service but there was also a jovial friendly atmosphere at the home. Care Homes for Older People Page 14 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Daily life in the home is made flexible and varied and where ever possible geared around meeting the preferences of the people who live there. The development of the activities programme to include more trips out would help to ensure that the social and therapeutic needs of individuals are met. Evidence: In their AQAA the Provider told us - Activities play a major role in the well being and happiness of our residents. We always listen to our residents needs and activities are oferred to those who wish to take part. We do have set meal times but food/drinks are available in between these, and, An open door policy in respect of visiting and, Meals are varied with the help of residents input. The above was found to be a reasonable reflection of what we found during the inspection. People told us that they liked the meals in the home, The meals are good here, and that they had a choice of menu. We observed the lunchtime meal being served, this Care Homes for Older People Page 15 of 29 Evidence: was steak and kidney pie or a pasta dish. Following this there was a homemade pudding served. People were obviously enjoying their meal. Staff were helpful with people who needed assistance. Meals were taken upstairs to two people who were dining in their bedrooms. We observed hot drinks being given out in between meals and the people we visited in their bedrooms had drinks of water and juice. Since the last inspection a staff member had been put in charge of activities but we were told that this person has since left and there is now a vacancy for this post. There is a programme of activities in place. We were told that people are encouraged to join in and we noted activities taking place in the lounge. A trip out to Walsall lights has recently been enjoyed by some people but surveys indicate that more trips out would be welcome - I would like a trip out now and again for a change of scenery. Entertainers come in from time to time and activities have included - A Halloween party, manicure sessions, arts and crafts sessions, a fireworks display was due to take place and a Christmas party has been booked. The surveys tell us - We should have more activities within the home and, I would like a trip out now and again for a change of scenery. They also said, Meals are very good. I like them. There is an open visiting policy at the home and some visitors were observed coming and going throughout the day. These relatives were visiting their loved ones in the privacy of their own bedrooms. Church services are held regularly in the home. Care Homes for Older People Page 16 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 who live in the home can be assured that any concerns they might have will be taken seriously and acted upon. The procedures adopted by the home help to keep people safe from abuse. Evidence: In their AQAA the Providers tell us - We take complaints seriously and will always act straight away. Protecting residents and maintaining their happinness and well being plays a very important part in the running of the home. The home has an open culture and people feel able to raise concerns with staff members and the manager of the home. They told us - Oh yes I would speak to the deputy or the manager - they are both very helpful, but then so are all the other staff. Visitors told us - Yes I would speak to the carer in charge or the manager Jean. Yes we have raised concerns in the past and these have been dealt with appropriately. We, the commission, have received 2 complaints directly about the home since the last Care Homes for Older People Page 17 of 29 Evidence: inspection and these have been referred to the Provider to investigate. There has been one safeguarding referral made as a result of one of these complaints. Since receiving the complaints the home has put improvements into place to address these concerns and has addressed them effectively. The home has a complaints procedure in place and this is prominently displayed in the reception area. The details of CSCI are out of date and will need changing to include our new address and telephone number so that people are able to contact us should they need to do so. People who live in the home are safeguarded from abuse by the systems in place at the home. We looked at staff recruitment files where it was identified that staff are very carefully selected to work at the care home. Staff undergo Criminal Records Bureau (CRB) and Protection Of Vulnerable Adults (POVA) as well as other checks before being offered employment at the home. When we spoke with staff they were knowledgeable about what might constitute abuse and how to report this. The staff receive instructions and training in abuse but this needs updating so that staff have up to date knowledge about local procedures. Care Homes for Older People Page 18 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 home is clean, well presented, homely and comfortable and is adapted to meet the needs of the people who live there. Evidence: In their AQAA the Providers tell us - We pride ourselves in providing a safe and lovely clean environment to live in all bedrooms are personalised by each resident and all rooms are single - some having en suite facilities. Improvements - We have refurnished quite a few bedrooms and replaced all furniture and carpets. They also said, There is a maintenance programme is in place and it is working welland, There is a new policy in place on hand washing. During this inspection it was identified that the above information is a true reflection on the home. We walked around the home and visited most of the bedrooms and all the communal areas. The home was clean, well presented and homely. Bedrooms were all different in layout and had been adapted to suit the needs of individual people. The bedroom of one person was specifically adapted so that she could spend most of her time here which is what she wants to do. The bedroom of another person is adapted to his needs Care Homes for Older People Page 19 of 29 Evidence: with things within easy reach. The relative of another person was seen tidying up his bedroom and the layout was exactly as the person wants it. We saw the bedrooms which had been redecorated and refurbished since the last inspection. The bedroom furniture is modern and attractive but the bedside drawers do not have a lockable facility. It is recommended that any new bedroom furniture incorporates a lockable facility so that people can keep store money and valuables safely in their room should they wish to. We observed the domestic assistant hoovering around the home - and commended her on the level of cleanliness. Most of the people who live in the home were sat in the main lounge but this was also a social setting where they were enjoying activities and chatting. The dining area was attractively laid out and all the people were accommodated for at the tables. However there were 2 people taking lunch in their bedrooms, as they wished. The Kitchen was clean and tidy and the cook was preparing tea. We were shown the last inspection report from Environmental Health and this is what they said about the home - I was pleased to note that the standards currently being achieved are well above average for this type of business. We saw the laundry, this is separate to the main building and satisfactory for the size of the home. Infection control guidelines are being adhered to and staff have received training in this area. The annexe was clean and well presented and homely. It was observed that some more comfortable easy chairs in the lounge area should be provided as most chairs are of the upright type. However the person who was sitting there said that he preferred an upright chair and was happy with the one he had. The garden area was seen to be pleasant and accessible to people who live in the home. Comments on surveys included I have never seen anything so spotless - they work very hard keeping it clean. This is a lovely clean home. Care Homes for Older People Page 20 of 29 Evidence: 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home are cared for by a staff team who have the knowledge, experience and skills to be able to meet their needs. The numbers of staff provided should be monitored to ensure consistency of care. Evidence: In their AQAA the Providers tell us - Staff we have at the moment are a good mix and work well together. We have improved on the interviewing and recruitment of new staff and improved with paperwork in staff files. My deputys role has changed over the last 12 months - she is now more involved in supporting me to run the home. Staff are more involved - we document meetings and staff training is more structured. At the time of the inspection there were 19 people accommodated in the home all with personal care needs. The deputy manager told us that there are some people in the home with slight dementia needs but that staff have received training in order to be able to understand and meet these needs. When we looked at training records and discussed this with staff they confirmed that they had received this training. Care Homes for Older People Page 22 of 29 Evidence: The number of staff on duty consisted of the deputy manager plus 2 other care staff. There was also a domestic assistant on duty plus a cook. The deputy manager told us that the manager is normally on duty. She said that from 3 pm until 10 pm there will be 3 more staff on duty - a senior carer plus 2 other carers. On night duty there is a carer awake plus 2 carers sleeping in and the manager on call. We spoke with all of the staff on duty at the time of the inspection. The deputy manager said, This is a really good home to work in and we are very well supported by the manager. She has done NVQ level 3 in care and has now commenced level 4 management. We looked at her staff file and found that the relevant required checks had been carried out prior to commencing employment at the home and there is evidence of training courses in place. We also spoke to a new starter who has worked in the caring profession for 10 years and was very impressed with this home - This home is brilliant to where I have worked before and, Its teamwork here. She explained that her induction training is good and that she has started to do her NVQ level 2 in care. She confirmed that she had to have a CRB and POVA check prior to starting and we checked her file and found this to be correct. We spoke with the third carer on duty. She has worked at the home for about 5 months. She told us that she is happy at the home and confirmed that she had received training in fire safety, moving and handling, catheter care, medication training, dementia awareness, and managing challenging behavior. We looked in her file and this was correct. Prior to the inspection we received the following comments about the staff at the home There is a rapid turnover of staff which leaves the staff under pressure, The home needs more staff, Oh yes they have good staff here, The girls are very kind and helpful, Nice caring and friendly staff. Care Homes for Older People Page 23 of 29 Evidence: We checked the staff duty rota for the previous and following 2 weeks and found this reflected the staff numbers present at the time of the inspection. The above comments are varied and suggest that staff numbers might not always be consistent or it may be that at times more staff are needed in order to meet the needs of the people who live in the home. Staff numbers should be closely monitored to ensure consistency of care. Care Homes for Older People Page 24 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 run and is managed in the best interests of the people who live there. Evidence: In their AQAA the Provider tells us - As the manager I take my responsibilities seriously and understand what the job role entails. I do not hold any residents monies any longer. The AQAA tells us that improvements in this outcome area have included - Tightening up paperwork, policies and procedures. I have started a new training plan and we are starting some NVQ 2. Both my senior staff have just completed their NVQ level 3 award. MY new cook has almost completed her NVQ level 2 in catering. My deputy has nearly completed her NVQ level 4 managers award and I have nearly completed my RM award. Staff are more aware of their job role now and there is a training board in the office. During the course of the inspection visit the above information was found to be accurate. Care Homes for Older People Page 25 of 29 Evidence: At the time of the inspection visit the registered manager was not on duty. We were met by the deputy manager. She was both welcoming and helpful throughout the visit. She explained her role in the absence of the manager and was aware of her responsibilities. She explained that she is NVQ level 3 qualified and is currently undertaking NVQ level 4 qualification. She has kept herself updated - attending training courses available to her including mandatory training updates. Examination of her training file confirmed this. We observed her interaction with the people using the service to be very good she knew all of them by name and was aware of their needs and preferences. People using the service spoke highly about both the deputy and the manager of the home, as did staff. One lady said - The matron is very nice - she is warm and friendly and, She is very good (referring to the deputy manager). Another person told us - They are all very good here - the managers especially. There is a Quality Assurance system in place in the home. Care plans are audited monthly as is medication. There are meetings for people using the service, which are held 3 monthly and we saw minutes of these. Questionnaires are sent to families 6 monthly, and there are 3 monthly reviews for people using the service. We were told that the people who live in the home deal with their own personal monies or this is done by their families/representatives. Two people have advocates. There is a Health and Safety Policy statement in place. Staff undergo regular mandatory training updates; the files seen confirmed this and staff told us about their training. We looked at records of the testing and servicing of equipment used in the home and these confirmed that equipment is maintained in good, safe working order. Fire safety equipment is tested and serviced regularly and there are regular fire alarm tests. Staff undergo regular fire safety drills. Care Homes for Older People Page 26 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 27 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 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 8 People should have their weight taken soon after admission to the home in order to provide a baseline for the monitoring of weight. Record charts used should be completed - in this instance the Antibiotic record chart contained in the care plan. The development of the activities programme to include more trips out would help to ensure that the social and therapeutic needs of individuals are met. The Complaints Procedure needs to include the new local CSCI details so that people have this information should they wish to contact CSCI. The abuse training for staff needs updating so that staff have up to date knowledge about local procedures. It is recommended that any new bedroom furniture incorporates a lockable facility so that people can keep store money and valuables safely in their room should they wish to. Staff numbers should be closely monitored to ensure consistency and to ensure that the needs of people are met in the home at all times. 2 3 9 12 4 16 5 18 6 19 7 27 Care Homes for Older People Page 28 of 29 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. 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