Inspection on 22/06/09 for Hollybank Residential Home

This inspection was carried out on 22nd June 2009.

CQC found this care home to be providing an Adequate 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

Hollybank Residential Home 21/05/08

Hollybank Residential Home 19/11/07

Hollybank Residential Home 28/11/06

Hollybank Residential Home 09/11/05

Hollybank Residential Home 28/04/05

Hollybank Residential Home 22/02/05

Hollybank Residential Home 15/06/04

Hollybank Residential Home 15/03/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report Care homes for older people Name: Address: Hollybank Residential Home 321 Chapeltown Road Leeds West Yorkshire LS7 3LL     The quality rating for this care home is:   one star adequate 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: Dawn Navesey     Date: 2 2 0 6 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 31 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 31 Information about the care home Name of care home: Address: Hollybank Residential Home 321 Chapeltown Road Leeds West Yorkshire LS7 3LL 01132628655 01132624660 denisemcevoy@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Select Choice Residential Services Limited care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Hollybank is situated in the Chapel Allerton area of Leeds, close to shops and places of worship, with good public transport links to the city centre. Buses stop outside the home and there is a small car parking area for visitors at the front. The home is registered to provide care, without nursing, for sixteen people over the age of 65. Accommodation is over two floors. There are eight single bedrooms on the ground floor with other rooms on the first floor accessible by a stair lift. Two of the rooms on the first floor are shared and the remainder are single. There are no en suite facilities although application has been made by the provider to register two new ensuite bedrooms, on the first floor. The communal lounge and dining areas are on the ground floor with communal sanitary facilities provided throughout the home. The current fees charged range from 423.26 to 456 pounds per week. There are Care Homes for Older People Page 4 of 31 Over 65 16 0 Brief description of the care home additional charges for hairdressing, newspapers and chiropody. The manager provided this information at the inspection of June 2009. More up to date information about fees and copies of previous inspection reports are available at the home. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate 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 1 star. This means the people who use this service experience adequate quality outcomes. The Care Quality Commission (CQC) inspects homes at a frequency determined by how the home has been risk assessed. The inspection process has now become a cycle of activity rather than a series of one-off events. Information is gathered from a variety of sources, one being a site visit. More information about the inspection process can be found on our website www.cqc.org.uk This visit was unannounced and was carried out by one inspector who was at the home from 10:35 - 17:30 on the 22 June 2009. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people living there. And also to monitor progress on the requirements and recommendations made at the last inspection. Before the inspection evidence about Care Homes for Older People Page 6 of 31 the home was reviewed. This included looking at any reported incidents, accidents and complaints. This information was used to plan the visit. An AQAA (Annual Quality Assurance Assessment) was completed by the home manager before the visit to provide additional information, however, the manager said this had been returned to us but we have no record of having received this. Survey forms were sent out to people living at the home but the manager said these were not received at the home. During the visit a number of documents and records were looked at and some areas of the home used by the people living there were visited. Some time was spent with the people who live at the home, talking to them and interacting with them. Time was also spent talking to staff, relatives and the manager. Feedback at the end of the visit was given to the manager. The last inspection of this home was on 21 May 2008. Care Homes for Older People Page 7 of 31 What the care home does well: What has improved since the last inspection? Some improvements have been made to the way medication is managed and recorded in the home. The manager also told us that the medication policy has now been reviewed. This all makes practice safer and makes sure people get their medication properly. More staff have now received training in safeguarding adults. This means that staff will respond properly if and when the need arises to any safeguarding issues. Activities in the home have been reviewed. People said they were happy with them and they have enough to do. Re-furbishment has continued at the home. A number of rooms have been reCare Homes for Older People Page 8 of 31 decorated as have the hall, stairs, landing and lounge. There are new fittings and furnishings in the lounge, which people said they were very pleased with. 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 on page 4. Care Homes for Older People Page 9 of 31 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 10 of 31 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 11 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. In the main, people who use the service can be sure that the home will meet their needs following assessment. Evidence: We looked at the assessments for the most recently admitted people to the home. Referrals had been made from care managers and the manager had made sure an up to date care management assessment of peoples needs was obtained. The manager said this information was then used as part of their assessment in making sure they were able to meet peoples needs. The home also carry out their own pre-admission assessment to make sure they can meet peoples needs properly. The information within them needs to have more detail and include some life history information. This would make them more individual to the person and give better information on peoples support needs. Staff said they would find it useful to know more about people before they had moved in to the home Care Homes for Older People Page 12 of 31 Evidence: so they could help them settle in better. The manager said they can carry out the assessments in peoples own homes or at the hospital if people are in hospital. She also said that people thinking of moving in to the home can visit with their families as much as they like before making any decisions about moving in. The manager is aware of how to access community support resources such as specialist nursing services. This makes sure they have the right support to meet peoples needs properly. People said they liked the home. Comments included: Its very good here, a nice home I really like it here. We spoke to some peoples relatives. One said, This is such a nice place, they are right good with them all. Care Homes for Older People Page 13 of 31 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall, the health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Evidence: People look well cared for clean, tidy and well groomed. Attention had been paid to detail. People had clean glasses, women had their nails painted if they wanted and people had their hair styled as they wished. Staff were patient, gentle and kind when interacting with people. They were discreet and respectful of peoples dignity when attending to any personal care needs. People who live at the home said they were well looked after. Their comments included: If you need a doctor they get you one Nothing is too much trouble. We spoke to relatives of people who live at the home, one said, They look after him well, he has been so much better since coming here, bright and more alert. We looked at care plan and risk assessment records for some people who live at the Care Homes for Older People Page 14 of 31 Evidence: home. At our last visit to the home we said that care records should continue to be worked on in order to improve them. The manager has reviewed the way in which care plans are developed, however further improvements are still needed to make sure peoples needs are not missed or overlooked. Some plans had clear and detailed instruction on how the needs of people who use the service are to be met. There were however, some shortfalls with some care plans and risk management plans. Some plans did not give the detail of how care needs are carried out. Terms such as needs help and needs assistance do not tell staff how much support a person needs and could lead to needs being overlooked. Some plans had conflicting information in them. For example one persons plan said they needed staff with them when they walked about the home, yet staff said this was not necessary. We also found that care plans and risk management plans had not always been signed or dated, making it unclear as to whether they were current. There were also plans that had been reviewed but the care plan was not then updated to show what the persons current needs were. Some staff said they felt the care plans were brief in their level of detail and they would like to see more personal, individual information available. One said, This would help us get to know people better. We therefore, still recommend that care plans and risk management plans are reviewed to make sure people using the service have an up to date, detailed care plan. This will make sure that people receive person centred support that meets their needs. Despite the gaps in care plan and risk management documentation, staff were familiar with peoples needs and could talk confidently about the support they give. Staff were able to describe peoples preferred routines with regard to their personal care and what works well for people. Help and advice is sought from health care professionals to make sure that people get the special help they need to maintain their health. People can be escorted to appointments by staff at the home. However, the manager said she likes to encourage peoples relatives to do this, to keep them involved in peoples care. We recommend that information on the provision of hospital escorts is included in the service user guide, so people are clear on what they are expected to do. Staff have been trained to meet the specific health needs of people who use the service. Staff said they had recently completed training in dementia awareness, Care Homes for Older People Page 15 of 31 Evidence: palliative care, diabetes and continence. Individual training is arranged according to peoples needs. For example, the district nurse giving training on a persons diabetes management. The home uses a monitored dosage pre-packed system for medicines. We checked some medication administration records (MAR) sheets. These were found to be in reasonable order. In the main, there are good ordering and checking systems in place. However, there were no records of the amounts of medication received into the home. This means it is difficult to audit stocks of medication or find out if any errors have occurred. The manager agreed to make sure this system was introduced. Care Homes for Older People Page 16 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience 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 able to make choices about their lifestyle. Social, cultural and recreational activities meet peoples expectations. They also benefit from a good, healthy and varied diet. Evidence: People who live at the home were happy about what they do at the home. Their comments included: Theres plenty for me, singing, dancing, playing games, I enjoy them all I like to sit for some peace and quiet in the dining room I enjoy the pretty little garden Theres always something going off. On the day of our visit, people seemed content and relaxed. Some people were listening to music and singing along, others were having a chat and doing some knitting. There is a weekly activity programme in place. On the day of the visit a quiz was organised in the morning and a motivational exercise class was on in the afternoon. People said they enjoyed them and only joined in if they wanted to. There was also a birthday celebration at tea time, with party food and drink being provided for the people who live at the home and relatives who attended the party. Staff also Care Homes for Older People Page 17 of 31 Evidence: said that more outings to places of interest had been arranged recently. Staff said they felt they had enough staff to provide people with a decent amount of activity and said they didnt feel people were bored at the home. Staff said they also felt they had enough time to just sit and chat with people.They said they also try to meet peoples cultural needs well. They said they get Kosher food for Jewish people and have made use of the Polish centre and shops for Polish people. They also said they have contacts within the community such as the Black Elders group, the Sikh centre and an Afro- Caribean food outlet. The atmosphere in the home is relaxed and life seems to go at the pace of people who use the service. People are free to move about the home as they wish and are able to have their things around them. Staff said they always ask people what they want to do, what to wear and make sure people can get up and go to bed when they want. Staff said there are no rigid routines for people. This is good person centred practice. People who live at the home were very positive about the food. Their comments included: Its always delicious Lovely food and do you a small portion if you ask for that Very nice food Will always do you something different if you dont like whats on. Menus are arranged based on likes and dislikes of people. This information is gained from people at the home, their relatives and staff. There is plenty of choice for people. There has been a vacancy for a cook at the home but this has now been filled, with the new cook due to start in the near future. The manager said the new cook was experienced and qualified in meeting peoples nutritional needs. The manager also said they have good links with the hospital dieticians who advise on any nutritional issues for people. Drinks are offerred regularly throughout the day and people said they can ask for one whenever they feel like one. We noticed that staff responded well and promptly to any requests for drinks or snacks. Staff are sensitive to the needs of people who find it difficult to eat and need help and encouragement with this. Staff gave support to people helping them feel comfortable and unhurried. Food looked appetizing and people were offered as many choices as required to encourage them to eat. The homes dining room was very warm and stuffy on the day of the visit. It is also quite small and when it was full with people having their meals it seemed quite cramped and people did not have a lot of space to move around in. The manager said she was considering introducing two sittings for meals to remedy this. Care Homes for Older People Page 18 of 31 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. In the main, people who use the service are able to express their concerns and are protected from abuse. Evidence: Most people we spoke to said they knew what to do if they were unhappy about anything and knew how to complain. They said they would speak to the staff, manager or their relatives. It was clear from staffs interactions with people that the people who live at the home seemed confident to raise their wishes or concerns. The home has not received any formal complaints directly since the last inspection. We received two issues concerning safeguarding matters. These have been investigated by the local authority and resolved with no action needing to be taken. The complaints procedure is reviewed and up to date and is displayed in the entrance hall of the home. The manager has also developed a new form for complaints to be recorded on. Most staff have now received training in safeguarding adults. The manager initially does this with staff on their induction and then makes sure they attend a course run by the local authority. Staff were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse. All staff were clear on their responsibility to report abuse or allegations of abuse. They were familiar with the whistle blowing Care Homes for Older People Page 19 of 31 Evidence: procedure and said they would have no hesitation in using it if they thought they needed to raise concerns outside of the home or organisation. The homes safeguarding adults policy does not however, contain the contact numbers to enable staff to do this. The manager is familiar with the local authority safeguarding referral system. This means people are properly protected. However, on the day of the visit, staff described an incident that had occurred between two people who live at the home. They said one person had attempted to strike another. We discussed this with the manager who said it was just an altercation between the two people and no-one had been at risk or injured. We looked at the daily notes to see if this had been recorded and it hadnt. We recommend that any events that occur between people who live at the home are recorded properly so that matters can be monitored and referred for safeguarding purposes if necessary. Care Homes for Older People Page 20 of 31 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall, the environment is homely, comfortable and safe for people who live at the home. Evidence: A tour of the building was carried out. Communal areas, bathrooms and bedrooms were visited. The home was clean, tidy and homely. Some bedrooms are for single use and some are shared. Mobile privacy screening is provided in the shared rooms. There are communal toilets and bathrooms with aids and adaptations fitted for peoples use. Staff work hard to make sure the home is kept clean. There are no malodours in the home. The manager has made sure there are good cleaning routines in place to make sure the home is clean and fresh smelling. People who live at the home were pleased with their bedrooms and had personalised them with their own things such furniture and pictures. Two new rooms have been added to the home. These are not yet in use as the provider is waiting to register them with us. These rooms have en-suite facilities. The manager said that once these rooms are registered and more people move in, staffing levels and routines such as mealtimes (as mentioned in the Daily Life section of this report) will be reviewed. Care Homes for Older People Page 21 of 31 Evidence: There is one lounge area in the home. This is fairly spacious, but is used as a thoroughfare to get access to some of the bedrooms. This means the rooms layout is restricted to chairs set out around the edges of the room, which doesnt always lend itself to assisting people to socialise and chat. A number of rooms have been re-decorated as have the hall, stairs, landing and lounge. There are new fittings and furnishings in the lounge, which people said they were very pleased with. On the day of the visit, there was no office space available for private meetings with staff or for staff to carry out their paperwork. The manager said the office was currently being used to archive old records for storage and she would make sure it was available as soon as possible. Clinical waste is properly managed. Staff have received training in infection control as part of their induction and were able to say what other infection control measures are in place. Hand washing and hand drying facilities were available in all areas of the home. Liquid soap or paper towels were available. This ensures good hygiene practice. However, uncovered toilet rolls were being stored at the back of the toilets. This is not hygienic and there is a risk of the spread of infection. The manager agreed to remove them during the visit and to look at alternative ways of storing them. Care Homes for Older People Page 22 of 31 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are overall, trained, skilled and in sufficient numbers to support people who use the service and to support the smooth running of the home. Evidence: People who live at the home and their relatives spoke highly of the staff. Their comments included: I feel the staff are well trained Staff are nice, they are wonderful, treat everyone like family Staff are very good to us. There are usually between three and four care staff on morning shifts and two or three on afternoon shifts. In addition to this there is an ancilliary staff member, responsible for cleaning and laundry and a cook. On nights there is one waking staff member and one who sleeps in to assist with any emergencies. People who live at the home and their relatives said there were enough staff. Their comments included: Theres always plenty of staff Theres always enough staff no matter what time of day we come We have enough staff, when you want them they are there Care Homes for Older People Page 23 of 31 Evidence: Staff also said they felt they had enough staff, that they never felt rushed and could meet peoples needs well. Staffs interactions with people who live at the home were respectful and caring . They showed they had respect for peoples individual needs, dignity and independence. We looked at the recruitment process for people working at the home. The files had the relevant information to confirm these recruitment processes were properly managed. This included application forms, references and CRB (criminal records bureau) checks. The manager said she also checks references by telephone to further protect the interests of people who live at the home. This is good practice. We recommend that the manager also records when she has done this. The manager has also involved people who live at the home in interviews for new staff to get their involvement in choosing staff. One person told us how much they had enjoyed doing this. We also looked at some staffs training records. These records showed induction training was on-going and up to date. They also showed that staff had undertaken training in a variety of topics. These included; fire training, moving and handling, infection control, medication, first aid and dementia awareness. At our last inspection of the home we recommended that the manager develop a training matrix, showing all training completed by staff. The manager has developed a training plan with training events arranged every month but this does not show clearly which staff have completed the training and when updates are due. We therefore still recommend that this is put in place. The manager runs the induction training on the skills for care common induction standards. Staff said they found this useful but had to wait for training courses to back this up, for example, moving and handling. We reccommend that staff are booked on training courses at the time of their induction so they gain the knowledge to enable them to work through their induction fully. Staff said they received good training and felt well prepared for their job. Staff were able to talk with confidence about how training had affected their practice. One said, they felt much better equipped to support people who have dementia since doing the awareness training. Saying, Communication and understanding people as individuals is key. There is a committment from the home for staff to complete an NVQ (National Vocational Qualification) in care in level 2 or above. This is good practice and means the home keeps staff who are qualified to carry out their job. One staff member said Care Homes for Older People Page 24 of 31 Evidence: they were about to now start their NVQ level 3. Care Homes for Older People Page 25 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall, the home is fairly well managed. The interests of people who use the service are seen as important to the manager and staff and are, in the main, safeguarded and respected. Evidence: The home has an experienced and qualified manager who also works alongside staff to demonstrate good practice. Staff said she was a good manager, open to ideas and suggestions and listens when staff tell her about issues to do with people who live at the home. The manager said she receives good support from the provider, who also now works at the home. We did not receive the homes AQAA (Annual Quality Assurrance Assessment). The home manager said it was sent to us but we have no record of ever having received it. The manager had not kept a copy of the document so we were unable to access it during the visit. Care Homes for Older People Page 26 of 31 Evidence: The manager sends out annual questionnaires to people who live at the home and relatives of people who live at the home asking for their views on any improvements that could be made. This years questionnaires have not yet been sent out but the manager said that last year people asked for the cooked breakfast to stay available every day, the suppliers of the homes sausages to be changed and a hot drinks machine to be installed for visitors. All of these things have been done, showing they listen and act upon suggestions made. The manager does not make the results of her survey available to interested parties as a published document but said that individual issues are discussed with those that raise them and feedback is given at residents meetings. Arrangements are in place to make sure of safe working practices. We saw the homes electrical wiring certificate was up to date. The home has a comprehensive range of health and safety policies and procedures in place. However, there is no index in these files and it can be difficult to find the policy needed. We recommend an index system is introduced to make it easy for staff to locate policies when they need them. The manager said she had recently gained a diploma in health and safety management. We looked at accident records in the home. The form used to record accidents is small and does not allow a detailed description of the accident or incident to be made and there is no space for follow up to accidents. The manager said she would review the forms used and already had some new ones to introduce. At our last inspection of the home we reccomended that the manager analyse all accidents and incidents in the home on a monthly basis. The manager said she looks at accident records but has not put anything in place to show how she analyses them to see if there are patterns, trends or ways of avoiding accidents in the future. We still recommend this is done. Staff said they received health and safety training from the manager during their induction. They also said they receive supervision where they have opportunity to discuss their job role with the manager. They said they find this useful. The manager said she had introduced a new form to record supervision notes individually for each staff member. She said she was finding this useful and made it easy to look back to see progress. Although records of accidents are kept in the home, the manager has not always been notifying the CQC of events which affect the welfare of people who use the service, such as falls, unless they resulted in a hospital visit. This must be done in future to make sure the health, safety and welfare of people who use the service is protected properly. Care Homes for Older People Page 27 of 31 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 28 of 31 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 9 13 An accurate record of the medication received into the home must be kept. This will make sure that medication can be checked properly and any errors easily identified. 31/07/2009 2 38 12 The CQC must be notified of any illness or other events which affect the welfare of people who use the service. This will make sure that the health, safety and welfare of people who use the service is protected properly. 10/07/2009 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 3 Pre-admission assessments should include more detail and some life history information. This will make sure that peoples needs are properly identified. Care Homes for Older People Page 29 of 31 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 2 7 People who use the service should have detailed care plans and risk management plans, clearly outlining all their support needs. This will make sure they receive person centred support that meets their needs fully. Information on the provision of hospital escorts should be included in the service user guide, so people and their relatives are clear on what is expected of them. The whistleblowing policy should include the contact details for agencies to contact outside of the organisation if staff wish to report concerns. Any events that occur between people who live at the home should be recorded properly so that matters can be monitored and referred for safeguarding purposes if necessary. The manager should develop a training matrix to use with the annual training plan to show the training each staff member has completed. This will make sure that mandatory training updates are not overlooked and that all staff have had the training they need to properly care for people. Some consideration should be given to booking staff on mandatory training at the time of their induction so they gain the knowledge to enable them to work through their induction fully. An index system should be introduced in the policy manuals so that staff can easily locate policies when they need them. Accidents and incidents in the home should be analysed on a monthly basis. This will make sure that any patterns or trends are identified. 3 8 4 18 5 18 6 30 7 30 8 37 9 38 Care Homes for Older People Page 30 of 31 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 31 of 31 - 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!