Inspection on 18/03/09 for Humfrey Lodge

This inspection was carried out on 18th March 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Humfrey Lodge 08/01/08

Humfrey Lodge 26/02/07

Humfrey Lodge 13/12/05

Humfrey Lodge 13/07/05

Humfrey Lodge 02/03/05

Humfrey Lodge 21/07/04

Humfrey Lodge 22/03/04

Humfrey Lodge 13/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Humfrey Lodge Rochelle Close Thaxted Dunmow Essex CM6 2PX     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: Helen Laker     Date: 1 8 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 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.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Humfrey Lodge Rochelle Close Thaxted Dunmow Essex CM6 2PX 01371830878 01371831187 humfrey.lodge@runwoodhomes.co.uk www.runwoodhomecare.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Runwood Homes Plc care home 48 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: 1. The registered person may provide the following category/ies of service only: Care home only Code PC 2. The maximum number of service users who can be accommodated is: 48 The total number of service users accommodated in the home must not exceed 48 persons to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category Code OP Dementia Code DE Date of last inspection 0 0 Over 65 24 48 Care Homes for Older People Page 4 of 30 Brief description of the care home Humfrey Lodge is a care home for older people over the age of 65 years. The home is registered to care for 48 people, 24 to 30 of whom currently may have dementia. The accommodation is all single rooms and is situated all on the ground floor. The home is divided into four units which each have communal rooms. There are a number of informal seating areas around the home and several garden and patio areas that are wheelchair accessible and secure. The home is situated in the attractive village of Thaxted in a residential area but close to shops and other amenities. The home is owned by Runwood Homes PLC. Fees for accommodation in the home are 467.95 pounds - 600.00 pounds per week and do not include hairdressing, chiropody, newspapers, transport, toiletries or clothing. Care Homes for Older People Page 5 of 30 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 star. This means the people who use this service experience good quality outcomes. This inspection was carried out as part of the annual inspection programme for this home. The manager was available on the day of the inspection. The inspection focused on all of the key standards. A tour of the premises was undertaken. Evidence was also taken from the Annual Quality Assurance Assessment (AQAA) completed by the management of the home and submitted to CSCI. The AQAA provides an opportunity for the service to tell us what they do well and areas they are looking to improve and/or develop. It is anticipated that some improvement be noted as this contributes to the inspection process and indicates the homes understanding of current requirements, legislation changes and own audited compliance. Most of the residents were seen and ten residents and four staff were spoken with during the inspection. Information was also obtained via completed CSCIs feedback Care Homes for Older People Page 6 of 30 survey sheets. All comments were taken into account when writing the report. The site visit also consisted of a tour of the home, observing the care given and reading of documents. The inspector would like to thank the staff and residents for their help and hospitality during the visit. 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. Care Homes for Older People Page 8 of 30 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 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 30 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. This judgement has been made using available evidence including a visit to this service. Prospective residents are supported by the transition arrangements for admission into the home and can be confident they will receive information to enable them to make a positive and informed choice about where they wish to live. Evidence: The home has a statement of purpose and a service user guide that have been updated and are on display in the reception area of the home. Feedback received from relatives indicated that a copy of the statement of purpose had been made available to them. The assessments of three recent admissions to the home since the last inspection were inspected. All of the assessments seen were noted to have been completed prior to or on the admission date and cover all the areas relating to the health and welfare of individuals. Attention to dates, times and signatures was discussed with the Care Homes for Older People Page 11 of 30 Evidence: registered manager, this must be given more prominence so it is consistently maintained. The registered manager reported that pre-admission assessments were undertaken by senior staff members or the manager at the prospective residents own home, hospital or at Humfrey Lodge depending on the needs and circumstances of the individuals at the time. The AQAA states Senior staff are trained and monitored in their ability to complete assessment information. Any provisional referrals are discussed within the senior team and the manager highlights specific needs the prospective resident may have and ensures that the prospective service users needs can be met. We welcome any prospective residents and family members to visit the home, with no appointment necessary. Residents spoken with reported that they had experienced this approach and found it helpful and reassuring. One service user spoken with stated After the first visit I knew I wanted to stay. Care plans are reviewed after the first month and regularly in consultation with the resident, families, representatives and the registered manager. One relative commented Communication is good and we always know what is going on with the care my relative has Humfrey Lodge does not provide intermediate care. Care Homes for Older People Page 12 of 30 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. This judgement has been made using available evidence including a visit to this service. People can expect that their needs are assessed in a person centred way that enables staff to have a better understanding of each individual, however people must be further assured that the care and support in some areas that they require to meet their needs is planned and recorded to guide staff in promoting their well being and safety. Evidence: There is an existing care planning system in place consisting of an assessment, care plans and risk assessments. Care plans cover the residents identified needs. They are generally informative and contain sufficient detail to ensure residents needs can be met. The completion of care notes was noted to vary depending on who had completed the entry. The quality of recording in the daily report section of the care plans varied greatly from good detail, cross referenced to specific areas of the care plan, to very basic information, this was discussed with the registered manager as this highlights a support need for staff via further training. The AQAA states that the home Care Homes for Older People Page 13 of 30 Evidence: plans to All care file documentation is much more comprehensive and detailed. We have improved structured handovers, which discuss key areas in the home, and expectations to improve the services. Monitoring in the home from myself and the CTM team. Every day the focus is where we are with the standard of care and if we can improve in any areas. The registered manager also reported that the format of the care plans is now more detailed and on going training was being provided to support care staff in maintaining clear and detailed records. Care plans include information on personal preferences and use a person centred approach concentrating on strengths, rather than needs and put support in place to optimise residents abilities. Risk assessments relating to all areas of life were present on the files with action plans to minimise any identified risks whilst supporting individuals to enjoy their lives. Records also included appointments arranged with healthcare professionals, weight and nutritional screening, personal safety, falls etc, the individual support required in such areas as personal hygiene, psychological and emotional needs, continence and communication. A protocol and monitoring process for falls has been developed which would correlate with the residents care plan and ensure staff make reference to the same when recording daily entries. Social histories are also formulated with the help of relatives and this ensures residents choices are considered. A monthly review system is in place and this is generally consistent. Those seen completed show a good staff appreciation of residents needs and changes, however attention is still required to include dates, times and signatures. This was discussed with the registered manager on the day of inspection. Work is being progressed to involve residents and their relatives in the care planning process, as this still needs to be addressed. The homes AQAA for this stated We will continue to develop clear communication, ensuring this is evident in written format, thus ensuring that staff are fully aware of the importance of effective communication. To continue to develop Care Team Managers within their role to ensure that they lead, direct the team and monitor both practical and written evidence. This was discussed with the manager on the day of this inspection, and we are assured changes are being made positively to provide a more holistic consultative process. Staff and residents who commented said that Residents are looked after well and staff are kind and caring. Reviews also can form part of the supervision process so residents can be assured that staff have a clear understanding of their care needs and the actions required to meet that need. Records show that doctors are asked to see residents in a proactive way and residents have access to the chiropodist and optician. A range of risk assessments are completed that include manual handling, falls, general and environmental and nutrition. Evidence that these are kept under review were on file. Some of these were brief in places and did not fully include details of how the risk was to be minimised. Records show that care staff ensure that blood tests are arranged, as requested by the doctor and that residents get to hospital appointments with escorts where Care Homes for Older People Page 14 of 30 Evidence: required. Residents are also accessing dental services in the community. The team use a blister pack - Monitored Dosage system MDS system to manage the majority of the residents medication. Medication Administration Records (MAR) sheets were generally neat, missing signatures and required information with reference to transcribed hand written prescriptions and omissions of medications has been addressed since the last inspection. Items are checked in to the home and returns systems are in place. With the further development of the care plans and the person centred approach this allows the team to evidence that they have a good appreciation of the diversity of the residents in the home. Staff approach to privacy is good, staff were seen knocking on doors and interaction between staff and residents was seen and heard to be friendly, caring and respectful. Care Homes for Older People Page 15 of 30 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. This judgement has been made using available evidence including a visit to this service. Residents can expect to be encouraged to maintain links with family and friends and to enjoy a balanced diet. Evidence: As noted at the homes last inspection the home employs an activities coordinator who works five hours daily with a care assistant also working in the afternoon. They have attended all required training including protection of vulnerable adults and sessions in dementia care. A snoozelum room has been established in the home to provide a designated area where residents can receive therapy to assist in calming them. The co-ordinator had also received training to enable her to be competent in this type of therapy. A range of activities were organised during the week (e.g. games, art and crafts, musical bingo, etc.) and were seen on the programme of activities that was displayed for information. Additional therapies were also provided including aromatherapy and hand massage. Individual records were maintained of residents assessment and involvement in the activities and were seen to include good detail of the outcome for residents who attended. The AQAA states The activities co- ordinator is very committed to her role and seeks the views of the service users regularly to Care Homes for Older People Page 16 of 30 Evidence: ensure that they receive the activities they wish to participate in. The service users enjoy a variety of crafts, games, reminiscence and arts. There are a number of entertainers that have been to the home, alongside themed events throughout the year. The service users enjoy relaxation times, which include aromatherapy, snoozelum and heat massage. Staff are encouraged to enable and involve the service users with activities of daily living such as washing up. Staff have taken residents out to the nearby market and in the gardens. We have two hairdressers that visit the home. Service users are actively involved in personalising their room and making every day choices. The service users have enjoyed outings and the local community have been to the home to deliver a service such as school singing, harvest produce, bell ringers, and Morris dancers. Ten residents were consulted as part of this inspection visit via discussions and survey responses, and all confirmed feeling satisfied with their lives at Humfrey Lodge. One stated It is lovely here you couldnt ask for more and another stated The staff do things with you but I would like to go out a bit more. The manager stated that the home would be undertaking themed cultural afternoons form different countries for example Germany Romania, Africa and the Phillipines throughout April and hope to introduce an mobile shop service and paper delivery delivery system. Residents said that their friends and relatives could visit at any time, and they could meet with them privately in their rooms. Staff reported that one residents spouse was able to join them for lunch each day. A church service is held in the home each month, and staff reported that some local community groups had visited the home at Christmas (e.g. bell ringers, local school children carol singing). All residents spoken with confirmed that their family and friends were welcome at the home at any time, it was reported that any visitors present over meal times could be invited to eat with them. Information on advocacy services was included in the statement of purpose and available in the home. Residents spoken with were clear that they had choices about their daily life in the home, especially in regard to where they spent their day, meals, etc. A physical tour of the building provided evidence to confirm that residents were able to bring their own possessions such as items of furniture and photographs into the home to individualise their personal space. The menu was arranged on a four weekly rota basis and included a wide variety of fresh produce. One main meal was offered daily. Residents praised the food highly and reported pleasure in being able to interact with the chef to give their feedback personally. Comments from residents included: That was really nice so I sometimes ask for more and The food is always good here The dining room at the home was pleasantly appointed and the lunchtime experience was observed to be relaxed and unhurried with staff providing discreet and sensitive Care Homes for Older People Page 17 of 30 Evidence: assistance where needed. The main meal served on the day of the inspection comprised roast chicken or toad in the hole with vegetables and potatoes. The meal looked and smelt appetising, and residents observed were enjoying this. Hot drinks were seen being served during the day, and water jugs were seen in residents rooms. Nutritional records were maintained on behalf of residents and those viewed confirmed that their weight was regularly monitored and nutritional supplements provided as relevant. Care Homes for Older People Page 18 of 30 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. This judgement has been made using available evidence including a visit to this service. Residents can feel confident about how to complain and can expect to be listened to and their complaints acted upon. Residents can also be assured that all carers are adequately trained to safeguard their welfare. Evidence: The residents at Humfrey Lodge are supported by the homes robust complaints policy and practices. The complaints records include details of any issues raised by residents or their representatives. None were observed to present any risk to residents health and safety however were generally treated with appropriate sensitivity and respect. All had been investigated and appropriate action taken where relevant. The AQAA informs us that Staff are trained in awareness of safe guarding and protection of service users. They are aware of the whistle blowing policy. This is reinforced in supervision and staff meetings, further awareness is gained through the staff handbook and displayed in house. In the staff room displayed, are related policies and procedures. We continue to protect and safeguard the residents at Humfrey Lodge by recruiting staff that have the relevant CRB and POVA checks. We are open and transparent within the culture of the home to ensure safe and good practice. Complaints and concerns are logged and acted on promptly in any event. Feedback from one visiting relative indicated that The home is thorough in its approach Care Homes for Older People Page 19 of 30 Evidence: Residents meetings are held regularly and the manager also offers drop in mornings at weekends for relatives to air concerns. Recorded minutes of these meetings provided evidence that individuals felt able to raise any points that concerned them. Records provided evidence that staff members had attended annual training in the Protection of Vulnerable Adults in December 2008. The AQAA informs us that the homes plans for the next twelve months include, To remain pro-active with our approach, ensure that the staff attend training as required with this area. Care Team Managers to continue to be vigilant in listening and act on service users views and reflective practice to move forward. To prevent concerns and complaints, by listening and remaining professional in our approach in the home and ensuring good care practice. Care Homes for Older People Page 20 of 30 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. This judgement has been made using available evidence including a visit to this service. People who use this service can expect to live in comfortable surroundings but cannot always be assured that there is always good odour control. Evidence: A physical tour of the building was undertaken with the manager. This tour included all communal areas and bathrooms, the laundry and some residents bedrooms. Most areas of the home were clean, fresh, homely and welcoming with no odours with the exception of one main area which had a strong smell of urine. Liquid soap and paper hand towels were provided for staff hand washing throughout the premises and staff were observed to follow correct procedures in hand washing, use of appropriate gloves and aprons and disposal of them in clinical waste bins. The laundry had two separate rooms for clean and soiled laundry. The laundry was well equipped with two washing machines, one with sluice cycle, two driers and rotary iron and domestic iron. These facilities were clean and functional. The AQAA informs us A comprehensive redecorating programme in place and full support from the companys facilities management team. A robust cleaning schedule is in place to ensure that all areas are attended to and monitored. The gardens are attended to on a regular basis by external services. Bathrooms have become more personalised. External services sought to attend to identify areas of repair i.e. the carpets and replace flooring in areas. The homes AQAA informs us that the home is in need of a full time Care Homes for Older People Page 21 of 30 Evidence: maintenance man at the moment and that contracted external services currently maintain the home. Residents are facilitated to make choices and influence the environment, as they are in the running of the home. The home is furnished and decorated to ensure that residents are cared for in a warm, safe, homely and attractive environment. Visitors are always welcome at any time and refreshments offered to them. Environmental risk assessments are undertaken on any area of concern. Equipment is well maintained and contracts are in place with specialist providers to ensure that regular servicing takes place and that all regulatory checks are undertaken. Furnishings are fire retardant and Portable Appliance Testing is undertaken regularly including equipment brought in by residents. Residents comments regarding the environment included It is a lovely place to be and It is my home and they look after us ok. The home is single storey and accessible to wheelchair users. Ramps are provided to enable access to the patio and gardens. There were grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided. Call systems were provided throughout all individual and some communal rooms. The surrounding gardens were attractive and well-maintained and accessible to residents. Staff training and annual refresher infection control training is planned and undertaken as part of the homes ongoing training programme. Care Homes for Older People Page 22 of 30 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. This judgement has been made using available evidence including a visit to this service. People living at Humfrey Lodge can expect to be cared for by skilled and experienced staff employed in sufficient numbers and who have been subject to robust recruitement checks. Evidence: Staffing levels comprised 1 care team managers and 7 care staff including staff on induction and were seen to be appropriate to the care needs of residents. Comments were received from relatives that care team managers are easy to talk and are helpful, and they are very caring people and do their jobs well. The AQAA states Over the last six months there has been a strong focus with the staff team in relation to the standards and improving them and giving staff the insight where it needs to be improved. Regular feedback, via day to day monitoring and meetings, to identify good practice and improvements in the home. There has been a drive of recruitment in the home, to date we now have a full complement of staff, so this will in turn mean no agency staff and promotes the opportunity to build a strong, stable staff team. Existing staff have been encouraged to undertake required mandatory training and the NVQ. Comments received from relatives stated they were generally confident in the care team and the managers who understand the care of elderly people and that previous use of agency staff did not now appear to be an issue. Ancillary staff also on Care Homes for Older People Page 23 of 30 Evidence: duty included the administrator, one maintenance person, 4 domestic staff, 1 laundry assistant, 1 cook and 1 assistant cook from 11am. The home had 14 care staff with NVQ level 2 training. A further 4 staff were working towards NVQ level 2 which is more than the recommended 50 of staff with NVQ level 2 training needed to meet the National Minimum Standard. The recruitment files of five recently employed staff were inspected. All had evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and copies of birth certificates, passports, and photographs obtained before the individuals commenced employment at the home. All had received a statement of terms and conditions of employment. The manager reported that all staff received induction to Skills for Care Standards and this was also confirmed from staff spoken with. The supervision records viewed were mostly variable in their content with some being comprehensive. The home has an established training programme that included regular updated training in dementia care. The records viewed also confirmed that staff had completed training on Protection of Vulnerable Adults, fire safety, moving and handling, first aid, health and safety and food hygiene. The AQAA tells us the home hopes to improve by Retaining a full compliment staff and develop them. Increase bank staff to cover such events as annual leave and any sickness. To improve open and pro- active communication in the home and a professional approach in which vigilance plays an important part in their roles. To encourage training and development in the home. To ensure that the Care Team Managers are pro active and provide clear, strong leadership with the staff team and good communication to all, evidenced and actioned as required. Care Homes for Older People Page 24 of 30 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. This judgement has been made using available evidence including a visit to this service. Residents benefit overall from a well run home. Systems are in place to ensure that residents views are included in the monitoring and review of the home. Residents can expect to be protected by the homes health and safety Evidence: There are clear lines of accountability evident within the home and the manager reported that good support is provided by line management within the company. The AQAA states that Prior to coming to Humfrey Lodge the manager had been commissioned and managed a larger home with higher needs dementia beds, which gave her the opportunity to gain valuable experience. She has completed the Registered Managers Award and have undertaken training in relation to dementia and a dementia trainer course whilst also currently undertaking a Psychology degree. The Care Team Managers have been in the home a number of years, so have a wealth of knowledge and insight between them. They have and continue to attend relevant Care Homes for Older People Page 25 of 30 Evidence: training to maintain and improve their knowledge base. There was evidence on the training records that all senior staff had undertaken regular and updated training since the previous key inspection. Feedback from relatives who completed surveys indicated that senior staff were approachable and they found them helpful. There is a corporate quality assurance programme whereby an annual audit is undertaken of Runwood care homes. An annual quality audit report from the audit undertaken during August 2008 by the quality team was seen. The home was commended in a number of areas including the warm, friendly atmosphere with customer care demonstrated, up to date staff supervision and efforts made to achieve NVQ targets. The home now undertakes daily floor audits and has monitored all complaints and compliments including introducing a suggestion box and wish list for residents and visitors where comments are used to improved standards. Relatives meetings have been held monthly since the home was registered. Visits required under regulation 26 had been undertaken. The home has secure facilities for the storage of any money looked after on behalf of residents. There were clear individual records of this, with receipts kept and cash held in individual zipped pouches. Monies inspected at this and the homes last inspection had appropriate records, receipts and cash all balanced. The home has a health and safety policy manual that included procedures for staff guidance and the records confirmed that all staff had attended relevant health and safety training. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities (e.g. evidence of electrical/gas certificates, PAT testing etc.), and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment and door closures, fire alarms and emergency lighting, hot tap water temperatures, etc.). Fire drills are not regularly undertaken and this was discussed with the manager who agreed to implement the practice regularly and to document names of all staff attending, times and dates to ensure safe practice is adhered to. Care Homes for Older People Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 26 16 (2) (k) To minimise the risk of infection: 1.Action must be taken to eradicate unpleasant odours from the home. 2.Handwashing facilities must be available where personal care is provided. 3. Staff must comply with the infection control policy in relation to the management of soiled linen. This is a repeat requirement. Timescale of 26/02/07 not met. 15/03/2008 Care Homes for Older People Page 27 of 30 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 1 26 16 To minimise the risk of infection: 1. Action must be taken to eradicate unpleasant odours from the home. This is a partially repeated requirement. Timescale of 26/02/07 and 15/03/08 not met in full To ensure service users are safeguarded from infection and live in pleasant surroundings 30/06/2009 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 7 Risk assessments should demonstrate how identified risks are minimised and it is recommended that some further training be undertaken to ensure all staff maintain a consistent approach with recording of the same. It is recommended that some further care planning training be undertaken to ensure all staff maintain a consistent approach with recording of the same. 2 8 Care Homes for Older People Page 28 of 30 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 3 38 Regular fire drills should be undertaken as part of the homes health and safety procedures and the date, time, and names of all staff attending documented. Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or 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) 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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