Inspection on 04/11/08 for Horsell Lodge

This inspection was carried out on 4th November 2008.

CSCI 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

Horsell Lodge 22/05/07

Horsell Lodge 28/11/05

Horsell Lodge 16/08/05

Horsell Lodge 15/06/04

Similar services:

Old Hastings House

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Horsell Lodge Horsell Lodge Kettlewell Hill Horsell Woking Surrey GU21 4JA     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: Mavis Clahar     Date: 0 4 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 31 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 31 Information about the care home Name of care home: Address: Horsell Lodge Kettlewell Hill Horsell Lodge Horsell Woking Surrey GU21 4JA 01483760706 01483771306 horsell@caringhomes.org Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Horsell Lodge Ltd care home 46 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 46 The registered person may provide the following category of service only: Care home only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - DE Mental disorder, excluding learning disability or dementia - MD Old age, not falling within any other category - OP Date of last inspection Brief description of the care home Horsell Lodge is a care home providing personal care for older people. Located in an exclusive residential area, Horsell Lodge is within close proximity of Horsell village. It is also accessible to shops and other community facilities in nearby Woking town. Set in Care Homes for Older People Page 4 of 31 Over 65 0 0 46 46 46 0 Brief description of the care home spacious, mature landscaped grounds, the building is a large, detached Manor house dating back to 1891. This was extended in 1947 and the modernisation programme over the years has retained the traditional architectural features of the original building. The home has good parking facilities and a secluded garden terrace and summerhouse. Bedroom accommodation is arranged on three floors accessible by passenger lifts. The home is wheelchair accessible except for the second floor and for this reason service users accommodated on that floor must be ambulant. Bedrooms are mostly singles, 24 of which have en-suite facilities. Three of the five shared bedrooms also have en-suite facilities. Communal accommodation is arranged on the ground floor, comprising of two lounges, a conservatory, main dining room, separate smoking room and dining/visitors room. Assisted bathing and shower facilities are available and wheelchair accessible toilets. Care Homes for Older People Page 5 of 31 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The last key inspection on this service as carried out on 22nd May 2007. The service also received an Annual Service Review on 23rd May 2008. Fees at this home are in the range of 320.00 pounds to 775.00 pounds per week. Charges for double rooms used as singles will be higher. This fee does not cover cost of hairdressing, chiropody and personal toiletries. This unannounced site visit, which forms part of the key inspection to be undertaken by the Commission for Social Care Inspection, (CSCI) was undertaken by Mrs Mavis Clahar on the 4th November 2008 and lasted for seven hours and ten minutes; commencing at 08:50 hours and concluding at 16:20 hours. Also assisting on this Care Homes for Older People Page 6 of 31 inspection visit was an Expert by Experience. This is a person who either has a shared experience of using services or understands how people in this service communicate. They visited the home with us to help us get a picture of what it is like to live in or use the service. This is important because the views and experiences of the people who use the service are central to helping us make a judgement about the quality of the care being delivered in the home. The registered Individual Mrs Wendy Lowther was present and Mrs Susan Allen manager of the home assisted on this inspection. The CSCI Inspecting for Better Lives (IBL) involves an Annual Quality Assurance Assessment (AQAA) to be completed by the service, which includes information from a variety of sources. This initially helps us to prioritise the order of the inspection and identify areas that require more attention during the inspection process. This document was received by CSCI (us) and is referred to throughout the report. The home has been without a registered manager for some time and the company has transferred the current manager from another home for which she is registered with CSCI as manager to manage this home. The manager has been in post since September 2008. The majority of the service users spoken to were able to express their thoughts and feelings about the care they receive and the food served to them. The information contained in this report was gathered mainly from observation by the inspectors, speaking with a number of service users, with the manager and Operations manager and with care staff. Further information was gathered from records kept at the home. The first part of the inspection was spent discussing and agreeing the inspection process with the manager, followed by a tour of the home, which included time spent in discussion with service users, care workers and the Chef. The manager and staff are aware of the Laws regarding equality and diversity and this was reflected in the staff mix. All service users in this home are Caucasian and reflect the population of the area in which the home is situated. All records sampled were mostly up to date with care plans not always being signed by the service users or by relatives. A number of requirements both immediate and longterm requirements were made on this visit. Please refer to the requirements page at the back of the report for more and fuller information regarding the requirements. The final part of the inspection was spent giving feedback to the manager and operation manager about the findings of this visit. We would like to thank all the service users and care staff that made the visit so productive and pleasant on the day. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 31 Care Homes for Older People Page 9 of 31 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 31 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective service users and their relatives have the information needed to choose a home, which will meet their needs and service users are being assessed to ensure the home is capable to meet the needs of the service users prior to being admitted into the home. Evidence: Review of service users documents and identified policies demonstrated the home has a policy and procedure on admission and discharge of service users. Within the admission policy all service users must have an assessment prior to being admitted into the home. The Manager, and in her absence, the senior carer who is trained in the principles of assessment of service users needs based on what care the home says it will provide carries out all Pre admission assessments of service users prior to them being admitted into the home. Care Homes for Older People Page 11 of 31 Care Homes for Older People Page 12 of 31 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a good and clear care plan in place for each service user and this includes appropriate risks assessments. This forms the basis for care based on the agreed care needs of the service users and demonstrated that trained staff met service users health and personal care needs. The homes medication policy on receiving, storing and administering of medication was in place and being adhered to thereby ensuring the safety and protection of the service users. Care workers treated service users with respect and maintain their dignity and privacy when delivering personal care. Evidence: The randomly selected care plans identified potential and actual risks to service users, detailing how these risks would be managed. The daily work sheet along with discussion with service users and care workers demonstrated that service users care needs are being met. The service user or relative have not signed the care plans to indicate their involvement in deciding the care service users received. The AQAA Care Homes for Older People Page 13 of 31 Evidence: informs care plans are developed from the Pre admission assessments with the involvement of the resident and relevant others as necessary. It was evidenced that care staff undertaking the development and monthly review of the care plans signed and dated them. We were told by the manager of the home that the care plan system is undergoing review with a view to change from computerised care plans to personalised care plans. All service users are registered with a local General Practitioner (GP) of their choice and visits are recorded, with access to specialist health care professionals through their GP practise as required and these visits are also recorded in the service users folder. Service users are offered access to chiropody service and weekly hairdressing facilities are available at a cost to the service users. In discussion with the Companys operational manager, the manager of the home and care workers they were extremely proud of the high standard of care they provided to all service users in the home. This was supported by the service users spoken to and by the review of the many letters of thanks received by the home. We observed care staff did not seem to be rushing in the delivery of care to service users. They were quite leisurely in their movements about the home. Care workers acknowledged service users as they passed them whilst employed on various tasks. We observed one service user who presented a very unkempt appearance and appeared not to have been shaved for several days. We were informed that the service user was regularly shaved in the afternoon. It would appear that this service user was not shaved the previous day and we were unable to find the right carer to verify the situation. Care staff identified as capable to administer medication are requested to leave a sample of their signature, which is dated and kept in the medication trolley. All service users have a recent photograph included in their personal folder and medication record, to reduce the risk of mistakes happening during medication administration. We were told by care workers that no service user on the day of the site visit was assessed as capable to self medicate. We reviewed the homes policy on selfmedication and this was found to be satisfactory. Medication records were checked and found to be correct as documented on the Medication Administration Record (MAR) sheet. We were told no service user at the home on the day of the visit was having any Control Drugs. Discussions about handling, recording and storing of Control Drugs in the home was satisfactory. Review of the homes record of receipt and disposal of medication was satisfactory, dated and signed. We saw no relatives at the home on the day of the visit. However, many of the service users Pre inspection questionnaires were completed by relatives on their behalf, and these were generally very favourable and complimentary to the staff. We observed that care workers wore name badges to enable visitors and service users with memory Care Homes for Older People Page 14 of 31 Evidence: impairment to be sure of whom they are speaking with. We observed Service users being treated in a friendly but respectful manner by care workers. Service users spoken to rate the personal care they receive as very good. We observed that service users were correctly dressed for the weather and that carers addressed them in the way they preferred. In rooms that are shared, screening is provided to ensure the privacy and dignity of the service user is maintained and upheld when personal care is being given or at any other time. Care Homes for Older People Page 15 of 31 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users lifestyles matched their needs and preferences and where possible they are able to maintain contact with family, friends and the local community. Service users are able to make choices in accordance with their abilities and were provided with a balanced diet in pleasant surroundings and in an unhurried way. Evidence: The home has trained one member of current staff to manage the activities programme for the service users. In agreement with the service users and their relatives a range of activities based on the individual assessed and agreed needs, including their preferences, cultural beliefs and customs is provided. Activity records are kept by the co-ordinator and also in the service users personal file. The AQAA informs us that activities include outside entertainers and outings in the homes mini bus. Touring the home we observed groups of service users chatting, and we were able to join in their conversations. We also observed one service user having a manicure in a small sitting room and in turn, other services users were being escorted to a spare room where hairdressing took place. We were told the home has good contact with religious denominations and Holy Care Homes for Older People Page 16 of 31 Evidence: Communion is provided for all service users who would like to participate. In discussion with service users we were told the home respects those service users who wish not to participate in an activity on any given day. A record of each service users daily activity is recorded in their care plans and their files demonstrated activities undertaken and refused. Service users told us visiting is open, and that they can entertain their guests in their bedrooms in private or in the spacious communal areas of the home. We observed that a variety of fresh fruits were stored in the home for service users. Four of the service users spoken to said they had choice in their clothing and sometimes they receive help from their key worker. On the day of inspection all service users were dressed appropriately for the weather. We were told the Chef is very new in post and has been at the home for only ten days. In discussion with the Chef he discussed his plans for improving the food served at the home. He told us he has planned a day (tomorrow) with the service users and the manager to discuss menus. He will operate from a four-week menu and there will always be a choice of two hot meals per day at mid-day, or salad at mid-day or the service user can choose their own food e.g. omelette etc. We were told the original menu was not suitable. One service user told us the Chef is very new and there is improvement in the food since he started. The Chef told us he tries to go around during the lunch period to ask service users opinion on their lunch to make sure they are satisfied with the meal. There is always a choice of two hot dishes for the evening meal, or they can choose to have sandwiches filled with their own choice. Morning coffee and afternoon tea is served daily. We were told the food budget has been increased and that the Chef manages the budget. We observed jugs of fruit juices and squash with glasses were placed in the lounges whilst service users were present, and staff was seen offering drinks to service users. We observed there were no fresh fruit available in the lounges and dining rooms so that service users could help themselves if they wished. The Chef informed us that they were low on stock today as it is the end of their food week and new stock were due in tomorrow. Service users said the pork chop was very tough. One Inspector sampled the lunch and reported that it was tasty. However, the pork chop although OK for her would not be suitable for Older people. In discussion with the Chef it was agreed that having pork chops on the menu was a good idea, but in future he might consider de-boneing the chop before cooking it so that it should not present such a challenge to older people to cut. We also observed small potatoes served with skins on and we overheard service users commenting unfavourably on this. Squash was served with the meal, but we observed no tea or coffee was served after the meal. One service user commented I Care Homes for Older People Page 17 of 31 Evidence: could do with a cup of tea but I suppose we will have to wait until tea time as usual. Other audiable comments about the lunch were Cant cut this, have you got a hacksaw? and Its disgusting, cant do this. Service users who were served soft meals were aided by carers attentively. The inspector observed the presentation of the food was done in a way to stimulate appetite. Lunch was served in the dinning room unless a service user requested to have their meal in their bedroom. We observed care workers interacting in a friendly but dignified manner with service users, offering help where it was needed. When we arrived at the home we observed breakfast was being served to the service users as they sat at tables arranged around a spacious dining room. A member of staff enquired what each service user required for breakfast. Generally the choices were egg and bacon or porridge. One service user requested more milk on her porridge and so her plate was removed, with additional milk to be re-heated. Service users can request breakfast to be served in their own room should they wish to do so. 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. The home has a satisfactory complaints policy and procedure and training in place that evidenced that service users and relatives concerns are listened to and acted upon.Robust Safeguarding adults policies are in place to protect the service users from abuse. Evidence: CSCI received one complaint about the home. Eleven complaints were logged at the home with seven complaints being substantiated and four unsubstantiated. The home is being managed by a new manager who haas been in post since September 2008 who is regestered by CSCI for another home within the group of homes. it was not possible to discuss the complaints with her as they occurred prior to her taking up the post. The new manager informed us that both her and the senior carer of the home are in touch with service users on a daily basis and issues raised are dealt with immediately; this prevents any need for service users to complain. We observed service users complaining about the pork chop served for lunch on the day of the visit and it was obvious they were not intimidated. Service users spoken to told us as a general rule they have no need to complain, as they are able to discuss everything with the manager/senior. However, they knew their rights and will complain if there is something to complain about and this is usually looked into straight away by the manager. The home has a complaints procedure and policy, which is adhered to. The care workers were aware of the homes policy and procedure on Safeguarding Adults Care Homes for Older People Page 19 of 31 Evidence: and felt secure in the knowledge that if they had to use the whistle blowing procedure the manager and the company would support them. It was observed that the homes guest information pack situated in reception contained a complaints procedure and policy, whistle blowing policy, statement of purpose and a recent copy of the last CSCI Key Inspection report for the benefit of all visitors to the home. We observed that the recent Annual Service Report completed on the home in May 2008 was not on display. The home has received a number of complimentary letters and cards from relatives of service users, commenting in a positive way about the care their relatives received at the home. A random sample of care workers training record demonstrated that care workers are being trained to undertake the duties of meeting the service users assessed needs, thereby protecting them from abuse. Planned programme of update on Protection of Vulnerable Adults (POVA) is planned for next year. 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. The physical design and layout of the home enables service users to live in an environment, which encourages independence, but does not always protect their privacy and dignity. Evidence: The home presents as an old house that had certainly seen better days. In various areas the floors creaked and groaned and in others the carpet had been stuck down and therefore could not be stretched when it became loose and wrinkled. We were told replacement procedure has been started. We were informed that the maintenance person had just returned from holidays. It was clear that the areas in need of attention were many and varied. On the first floor kick boards on the bedroom doors were damaged, broken or cracked. A bath end panel was broken and the shower hose in the same bathroom was wrapped around the taps. Both these areas are hazardous from a health and safety view point. In another bathroom the floor beside the bath was weak and dipping when one stood on the spot and a hole was discernible under the lino. This bathroom was immediately closed by us. We observed two ceiling roses were not replaced to cover exposed live electrical wires in one bedroom. Immediate requirements were made to have thse health hazard remedid within twenty-four hours. Care Homes for Older People Page 21 of 31 Evidence: We observed clean linen being stored on the floor in the linen cupboard, subject to dust and dirt. Immediste requirement was made to remove the linen. The door jam should be made safe in the service users toilet at the end of the lounges. All double bedrooms must have suitable divider in place to ensure the privacy and dignity of the service users are maintained. In discussion with the manager we were told the home has a five year maintenance plan but this document could not be found on the day of the visit. We observed that some redecoration has been carried out at the home, but there are still areas which needs a great deal of repair and repainting for example over the steps and leading down to the laundry where the paint work is chipped and the walls are cracked. We were told management and staff encourage service users to see the home as their own home. It presents as a comfortable but tired home, which has all the specialist adaptations, needed to meet the service users needs. It was noted that call bells were left within reach of each service user and service users said the bells are usually answered promptly. The home has attractive gardens, which are well maintained and there is good access to the gardens from various parts of the home. The inspector noted that adverse weather would not stop service users enjoying the garden, as the windows are low enough to allow service users to view the gardens from their armchairs. It was noted that service users were able to personalise their bedrooms with photographs and paintings on the walls. We were told that all the furnitures in the bedrooms are owned by the home. A number of Requirements including immediate requirements were made to ensure the health and safety of service users and staff were not compromised on the day. For more information on these requirements please refer to the requirements page of this report. Prior to completion of the visit the CLOSED bathroom on the first floor was repaired and was re-opened by us. Telephone communication with the manager of the home on Wednesday 5th November 2008 confirmed that all immediate requirements issued on the 4th November 2008 have been completed. 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 trained, skilled and in sufficient numbers to fulfil the aims of the home and meet the changing needs of the service users. Evidence: The staff rota demonstrated the number and grade of staff on duty to provide care and attention to service users for any twenty-four period was suitable to meet the assessed care needs of the service users. The home has a programme of planned training in place and all members of staff have an individual training record. Over 50 of care workers have attained the National Vocation Qualification at Level 2 (NVQ L2) or above. Care workers are encouraged and enabled to undertake developmental training as well as the mandatory training. All newly appointed staff undertakes the Skills for Care Common Induction programme. The home ensures that staff undertakes the mandatory training with yearly updates as necessary to maintain their competency to fulfil their duties. This was evidenced through discussion with the deputy manager, and operations manager and review of carers training records. Two of the three care workers files sampled contained Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checked prior to commencing employment, Care Homes for Older People Page 23 of 31 Evidence: and they are in receipt of terms and conditions of employment, as evidenced in their randomly selected files, which contained the information required under care Homes Regulations 2001 Schedule 2. One care worker was being worked under supervision on receipt of her POVA check until the CRB is returned. The manager told us that supervision records were up to date and this was verified during random sampling of care workers files. Documented evidence indicated that the home ensures that care workers receives the mandatory training with yearly updates as necessary to maintain their competency to fulfil their duties. This was evidenced through discussion with the manager and care workers. Service users appear to understand all the carers and support workers that were observed on the day. There were a variety of ethnic groups represented within the care staff they were all able to speak and understand English and to make themselves understood. Care Homes for Older People Page 24 of 31 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has the experience to run the home and works to continuously improve services and provide an increased quality of life for the service users. There is a strong ethos of being transparent and open in all areas of running the home and the views of service users and their relatives are actively sought. Service users financial interests are safeguarded and the health, safety and welfare of service users and staff are protected and promoted by the homes policies and procedures. Evidence: The home has been without a registered manager for some time. The company has in September transferred an experienced manager from another home within the group to manage this home. The new manager is currently registered with CSCI for the home she managed until being moved. Care Homes for Older People Page 25 of 31 Evidence: The AQAA informs us that the manager has demonstrated that she has kept herself updated on issues relating to care of the service users and staff in her charge. She is a Registered General Nurse on the live register of the Nursing and Midwifery Council and has attained the Registered Managers Award. There are clear lines of accountability within the home, each member of staff spoken to on the day of inspection aware of their role and responsibilities. We were told that the majority of the service users are capable to be fully involved in the running of the home, and their relatives are encouraged to be as involved as their time allows them to be. It was obvious from the minutes of the records of residents meeting reviewed that no meeting had taken place for some time and in discussion with the new manager we were informed this was about to change, as she was planning a resident meeting this month. The manager informs us her plans for the home includes treating the residents of the home as part of a large family and meetings will be held at regular intervals to allow service users, their relatives, carers, and manager to discuss issues pertaining to the smooth running of the home. Every one will then able to contribute to the running of the home, whether it is to change the four weekly menus or to replace major items in the home. The operations manager explained that this approach is preferable by all concern parties as any occurrence in the home affects us all. The home does not become involved in service users finance. The relatives/court manages all their finance. Good records are kept with receipts for any expenditure. Review of documented records demonstrated that health and safety checks are routinely carried out at the home. All equipment examined on the day were properly maintained. The AQAA informs that fire drills, fire alarm, and water temperature were regularly checked and records kept verifying this. Random sample of care workers training files demonstrated that up to date and relevant training were carried out by care workers to protect service users health, welfare and safety. Throughout the service there is a highly evolved understanding of the equality and diversity needs of the individual service users. Care workers are confident in delivering high quality outcomes for service users in the areas of age, sexuality, gender, disability and belief. Although the care workers are knowledgeable about issues relating to race and equality and diversity, they are not able at the moment to put this knowledge into practise, as the current service users are all Caucasians. Care Homes for Older People Page 26 of 31 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 19 16 a)Repair the door jam in 27/01/2009 service users toilet situated at the end of the lounges. c) Repair the kick boards on bedrooms 55 and 53. d)Replace the perishing rubber on the side of the wall in the bathroom opposite bedroom 55. Also remove the mark on the floor which looks like staining. b) Repair the damaged carpet in the big lounge. The care home must be kept in good state of repair both internally and externally. 2 26 16 All double bedrooms are to have suitable divider to ensure service users dignity and privacy are maintained at all times. 27/01/2009 Care Homes for Older People Page 29 of 31 Rooms occupied by service users must have adequate furnishings including screens where necessary. 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 Care Homes for Older People Page 30 of 31 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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. 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