Inspection on 12/11/08 for Kettlewell House

This inspection was carried out on 12th November 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Kettlewell House Kettlewell Hill Chobham Road Woking Surrey GU21 4HX     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: Lisa Johnson     Date: 1 2 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (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 29 Information about the care home Name of care home: Address: Kettlewell House Chobham Road Kettlewell Hill Woking Surrey GU21 4HX 01483756362 01483841809 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Kettlewell House Ltd care home 29 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 29. The registered person may provide the following category/ies of service only: Care home with Nursing - N 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 - OP Dementia - DE Date of last inspection Brief description of the care home Kettlewell House is a large detached property, situated in a semi -rural location , a short distance by car to Woking Town Centre. The home is owned by Graham Care Group who also have a number of other care homes in Surrey, Kent and Sussex. The home provides accomodation, care and support to twenty nine older people and those with dementia over 65 years of aged. The home has recently been refurbished by the new owners and provides modern facilities. Accomodation is situated over two floors and a passanger lift is available. Bedrooms are in the main of single occupany and have en suite facilities, although there are two double bedrooms. There is a spacious Care Homes for Older People Page 4 of 29 29 0 Over 65 0 29 Brief description of the care home lounge and dining room which has retained some of its original character such as wood panelling. The home provides fully assisted toilets, bathrooms and to wet rooms to assist people in maintaining their indipendence. There are extensive gardens to the rear of the property and car parking is available at the front of the property. The weekly fees range from £900- £995 depending upon the size of the bedroom and view. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This visit was part of a key inspection. The site visit was unannounced and took place over eight and half hours commencing at 9.AM and finishing at 5.30pm. Mrs. L Johnson regulation inspector carried out this visit. Mrs. H Stace registered Manager represented the service. Information was provided to us by the service prior to this visit in the Annual Quality Assurance Assessment (AQAA). This is a self assessment that focuses on how well outcomes are being met for people using the service. Reference is made to this document throughout this report. During this visit we spoke to four people who use the service and five members of Care Homes for Older People Page 6 of 29 staff. We received seven feedback surveys from people who live in the service or that had been completed by their representatives on their behalf. We also received surveys from four health care professionals.We also had the opportunity to speak to the homes new owner During this visit we conducted a full tour of the premises, looked at care plans, risk assessments, staff personnel and training records and policies and procedures. The inspector would like to thank the people living in the service, their representatives, managers and staff for their time, assistance and hospitality during this inspection. What the care home does well: What has improved since the last inspection? What they could do better: There were no requirements made as a result of this visit Care Homes for Older People Page 8 of 29 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective people considering the home as a place to live have the information they need to make an informed choice about its suitability. People are provided with a contract which includes information how much they will pay and what the service provides. A full needs assessment is carried prior to admission to the which people and their representatives have been involved in. Evidence: The service has developed a comprehensive statement of purpose and service user guide which gives a clear description of the support and facilities that the service is able to provide. We were informed that this information can be provided in alternative formats. The service has developed a new published website which is enhanced with the inclusion of pictures and video clips which provide further detailed information to prospective people and their relatives considering the home as a place to live. Seven people surveyed said that had received information about the home prior to admission. Care Homes for Older People Page 11 of 29 Evidence: Information supplied in the AQQA states that people and their representatives are encouraged to visit the home and they are offered the opportunity to stay for lunch and/or activities as part of the assessment process. A persons representative said, We were very impressed by the information and advice given by the manager. Detailed and comprehensive Pre- admission assessments are conducted by the registered manager prior to any person moving into the home ensuring that their needs can be met. Pre admission assessments sampled included information about peoples life histories health, personal care, mental wellbeing, communication, mobility including history of falls, aids and adaptations, medication, nutrition, social interests, hobbies, cultural and religious needs. Information gained through this assessment assists in formulating the care plan. Pre- admission assessments are signed and agreed by people or their representatives. People and/or their representatives are provided with a contact detailing the terms and conditions of the service and includes information about how much people will pay. Contracts had been signed by people or their representatives and the service to confirm their agreement. The home does does not provide support to people for intermediate care. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples health, personal and social needs are met , they have a plan of care and they are treated with respect and their privacy is respected. People living in the service are protected by the homes medication policies and practices. Evidence: The registered manager has introduced a computerized care planning system (Residata). Care plans were based on full assessment and cover all areas of activities daily living. People using the service and their representatives can view their care plans on line through the homes website and can receive an E mail alert which tells them when changes have been made which gives them an opportunity to review the changes and to discuss with staff. We were informed that there are safe security systems in place ensuring that only the relevant people involved can access this information. Four care plans were sampled during this visit and information seen demonstrated that monthly care plan reviews take place and that people and their representatives are consulted ,who had signed their care plan to confirm their agreement. Care Homes for Older People Page 13 of 29 Evidence: The home has a key worker system in place and daily records are completed twice daily. Each day a different area of activities of living is concentrated on to ensure that evaluation takes place of all aspects identified in the care plan. The health and personal needs of people were clearly recorded in their care plan and how this is to be provided and in the way that people prefer. Peoples likes and dislikes were also recorded including favorite meals and drinks. One persons care plan identified that they require the assistance of a walking frame when mobilizing. Risk assessments were in place in relation to mobility, tissue viability and nutrition including close monitoring of weights . Information seen during this visit demonstrated that action is taken when any changes are identified which were clearly recorded and the action taken. The home also supplies pressure relieving equipment and one persons care plan identified where this was required and specified the action to ensure prevention . During this visit the manager showed us the systems in place for monitoring and identifying people who may be at increased risk of falls and how this is managed. The service is supported by a local General Practitioner and referrals are made through them to access range of health care professionals including chiropodist, optician, and nurses. Three health care professionals surveyed said that peoples health needs are met by the service. A visiting health care professional said, Since the home has been under new management and the home has been refurbished it has improved in all ways. Staff and residents seem very happy and contented. During this visit staff were seen to be attentive and respectful to people throughout. Bedroom and bathroom doors were shut when carrying out personal care respecting peoples privacy. One person told us that staff always knock on their door before entering and they prefer spending time alone which is respected by staff. However a survey received on behalf of one person living in the home stated that a curtain that had been removed due the the redecoration had not been replaced in their shared room and the privacy the other person in the room had not been respected by a member of staff. This matter was discussed with the registered manager who was aware of this matter, which was being followed up. We were also informed that new dividing curtains had been purchased and that these would be fitted the following day. The homes medication policies and practices were examined. Medication was appropriately stored and maintained in a medication cupboard in the clinic room which was also locked. All quantities of medication received by the home was recorded and Care Homes for Older People Page 14 of 29 Evidence: disposal systems were in place. Only staff that have received training administer medication and a list was maintained of these staff. A protocol was in place for the administration of homely remedies.Medication administration records contained a picture of the person for identification. All medication administration records had been signed. Although one persons medication card had been hand written by staff which had not been checked by two members of staff, this was bought to the attention of the registered nurse and manager. This matter was attended to during this visit. The support that people require with their medication was recorded in their care plan. We were informed that where people are able to take their medication they are able to. A risk assessment for one person was sampled during this visit which confirmed this Care Homes for Older People Page 15 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is demonstrating that they are making progress in ensuring that people are provided with recreational and social activities that meet their personal needs, preferences and interests. People maintain links with their family, friends and representatives. People are provided with nutritious and well presented meals and snacks Evidence: The home is demonstrating that they are making good progress with developing and improving recreational and leisure activities which meet peoples needs and preferences. The service has employed an activities coordinator who has experience of working in this role. It was also positive to see staff joining in and supporting these activities which is seen as part of their role as well. A persons representative said, There is regular programme of activities throughout the week. We were informed that one person likes to lay the tables for meals and helping with the laundry. At the time of this visit some people were taking part in floor games and in the afternoon a visitor attended the home and provided musical entertainment which provided a very enjoyable atmosphere where people were participating and Care Homes for Older People Page 16 of 29 Evidence: taking part. The activities coordinator told us about some of the developments that have taken place . Activity resources have been assessed and a range of new equipment has been purchased. The service has joined an organization that specialises in activities for older people and large print books have been obtained from the visiting mobile library. Some entertainers visit the home , a pat dog attends and aromatherapist visits monthly.The service has registered as a user of the reminiscence collection at the library and have obtained some resources. The service has also introduced gardening for people with the provision garden tools which have been have all been risked assessed. Other activities introduced include reminiscence, crafts, exercise and individual one to one sessions. The service intends to enhance the lounge environment to make it more stimulating, provide, more sensory activities and they are considering setting up a sensory room . The service is intending to arrange and increase activities such as themed days and to make use of the community bus and to increase links with the local community such as schools. A regular visitor to the home said, The activities are very good and staff seek to find residents that do not get as much attention as they are unable to join in some activities, so its nice for them that they get some individual quality time such as massage. One person said that that the afternoon activities were not as varied. Peoples religious and spiritual needs are respected and the service holds weekly Sunday services with volunteers from the local church. The local Church of England minister visits once a month to offer communion and occasional visits are received from the Roman Catholic priest and the manager has arranged for one person to receive a visit from the Christian Science and two people attend church with their family Birthdays are celebrated and the cook prepares a birthday cake. Information supplied in the AQAA states That the service encourages people to maintain links with their family, friends and representatives and visitors are welcome at all times. People can meet with their visitors in the communal areas or if they prefer they can receive their guests in their bedroom. Telephone facilities are available for people if they wish to have a telephone in their bedroom to maintain contact and the home has a cordless telephone for taking calls. People moving into the service are able to bring in their personal items such as furniture. People living in the service have been fully consulted about the refurbishment and development of the home and have been asked about their Care Homes for Older People Page 17 of 29 Evidence: preferred choice of carpets, decor bedding and curtains. One person requested that they preferred a wooden floor and white walls which was confirmed by this person and had been completed to their preference. This person prefers to sleep on a futon on the floor and their preference for this is respected by staff . The home has introduced an orientation which is completed each morning and includes information about the date, day, weather and the menu.The service has also ensured that everybody is included on the electoral role. The home has has a four weekly rotating menu which was varied and nutritious. All meals are prepared in the home. Discussion took place with the cook who stated that all meals are prepared using fresh produce. A choice of two cooked meals available at lunchtime and at supper, although it is recommend that this is stated on the menu. People meet with the chef to discuss their preferences. The chef serves the meal in the dining room and the lunchtime meal was well presented. Snacks and refreshments are available throughout the day and in the afternoon freshly baked scones were offered for mid afternoon tea. The dining room offers a comfortable dining experience and tables were provided with cloths and napkins. People were provided with clothes protectors where these are required any any specialist equipment. Appropriate numbers of staff were available to assist people who require assistance with their meals. The meal time provided an unhurried and relaxed atmosphere ensuring that that this was an enjoyable experience for people. One person told us that they prefer to take their meals in their bedroom which meets their preference and that they always provided with a choice. Three other people said that they enjoyed their meals and a representative stated on behalf of a person , The meals are very good and another person said, The food is appetizing and well presented and particular care is taken to provide suitable to meet by relatives needs Care Homes for Older People Page 18 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that their complaints and concerns will be listened to and they are protected from harm Evidence: The service has a complaints procedure, which is available with the service user guide. The manager stated that any complaint or concern will be listened to and addressed. Since the home has been re registered no complaints have been received and none have been brought to the attention of the Commission. When the refurbishment is completed the manager intends to make this information visible and on display. Six people or their representative surveyed said that they know how to make a complaint and know who they can talk to . Five out of six people said that staff listen to what they say. The service has their own internal safeguarding vulnerable adults from abuse and whistle blowing policy in place and follow the local authorities safeguarding procedure, which was also available. Information seen on staff training records that were sampled confirmed that staff had received appropriate training. We also spoke to four members of staff who were aware of their responsibilities should they witness or are made aware of any incident where the safety or protection of a vulnerable person is compromised. Since the home has been re registered there have been no safeguarding referrals made. Care Homes for Older People Page 19 of 29 Care Homes for Older People Page 20 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is demonstrating that the refurbishment of the home will provide people with a safe, comfortable, clean and spacious home to live in, although further work is needed to improve the appearance and safety of the garden. People have comfortable bedrooms to stay in with their own possessions around them and they are provided with specialist equipment to maintain their Independence Evidence: Since purchasing the home the new owners have invested in carrying out a major refurbishment programme to improve the environment ensuring that people living in their have a safe, comfortable and well maintained home to live in. The work is nearly completed and the finishing touches are being applied.The main lounge has been opened up providing a spacious environment for people to move about in. and included a large flat screen television installed on the wall. There is an attractive dining room which provides an attractive place for people to take their meals in and retains some of its original features including wood paneling, which has been complimented by the purchase of new furniture. A new care stair case has been installed and bedrooms have been refurbished, redecorated and new carpets and flooring have been fitted . All beds have been Care Homes for Older People Page 21 of 29 Evidence: replaced with specialised profile beds. A majority of the bedrooms are single occupancy, and have their own en suite facilities, although there are two double bedrooms. We were informed that people and their representatives have been fully consulted about the refurbishment and that disruption to people ahas been as minimal as possible. We were informed that people have had the opportunity to choose their preferred color schemes. Window restricters and key pad entry systems have been installed ensuring peoples safety. A new call bell and fire system has been installed. Specialist equipment has been provided including assisted toilets and bathrooms and two wet rooms have been provided ensuring accessibility to people. Handrails were provided throughout. The manager informed us once the work is fully completed they intend to provide signage to assist peoples orientation. There is a large garden at the rear of the house which is used by people in the summer months with staff supervision. Further improvement has been identified and the work is due to take place in the spring. During this visit the home was observed to be cleaned to a good standard and was hygienic and no pervading odours were present. Infection control procedures are in place and staff receive training. Separate laundry facilities are provided, which are situated away from the main living areas. The manager has identified that they wish to make further improvements in this area. Care Homes for Older People Page 22 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by sufficient numbers of staff who are trained and competent to carry out their role. People are protected by robust recruitment policies and practices. Evidence: The duty rota was examined during this visit, which reflected the names and numbers of staff that were on duty at this time. People living in the service were supported by a registered general nurse, five carers plus the registered manager. At nighttime one senior and two carers are provided. The manager told us that staffing levels have been assessed using the residential forum matrix. Ancillary, catering, administration and maintenance staff also supports the home Surveys received from people using the service indicate that staff are available when they are needed. There has been some staff turnover but vacant posts have all been filled and the home is now fully established. One person said that sometimes there are not as many staff available , they are always busy and its difficult to find somebody. Recruitment is based on equal opportunities policies and people are supported by a staff team who are of mixed cultures and ethnicity.Since taking over the home the manager has reviewed the performance of each member of staff and where it was identified that there were deficiencies in training support has been provided. Care Homes for Older People Page 23 of 29 Evidence: Currently fourteen care staff have obtained National Vocational Qualifications (level 2) or above and a further eight members of staff have been enrolled on to the programme. New staff receive induction and follow the Skills for Care core induction standards, which were available to view on members of staff personnel files. Mandatory training is on a rolling programme which includes moving and handling, infection control, safeguarding adults from abuse, food hygiene and fire safety. The training records were sampled for four members of staff, which demonstrated that they are, have received or are booked to attend refresher courses. Staff spoken with told us about the training they have received who all said that they felt well supported Since taking over the management of the home twenty staff have been booked on a level 2 Asset Accredited Dementia course. This training is also being provided to the homes chef and activities coordinator. Some staff spoken with told us that this in process. Recruitment files were sampled for four members of staff which contained the required information including a fully completed application form, two written references, Protection of vulnerable adult first checks (POVA) and enhanced criminal record bureau checks (CRB). A file sampled for a qualified nurse contained a copy of their up to date personal identification number, which ensures that they are registered and competent to practice. The manager informed us that staff have been made aware of the General Social Care Code of conduct (GSCC). Care Homes for Older People Page 24 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run by an experienced manager which is being run in the best interests of people living there. Peoples financial interests are safeguarded and their health and safety is protected. Evidence: The registered Manager is a registered general nurse, holds the registered managers award and has obtained a diploma in dementia care. The manager is very experienced in managing services and raising standards in residential care settings. Both the new owners and the manager are demonstrating that significant steps have been taken to the improve the service provision. During this visit the manager was observed to have an open and friendly approach and made her self accessible to people, visitors and staff throughout. Staff spoken with during this visit spoke very positively about the support they receive from the homes management team and the improvements that have taken place. One Care Homes for Older People Page 25 of 29 Evidence: member of staff said, it is a wonderful place to work and there is good team work. Another person said, the manager is approachable and always available for advice. The owner visits the home often and meets with people, relatives and staff and to discuss the developments that that are taking place in the home. Monthly quality monitoring visits are conducted and reports sampled were detailed and comprehensive included outcomes of observations, interviews with people living in the service and staff. The service has already provided feedback to surveys to people and their representatives to gain their views on the care and support provided. The outcome of these have been analyzed by an independent organisation. The service is using these outcomes as a basis to continue to to improve and develop the service. The home also holds regular consultation meetings with people living in the service who have been kept up to date with the redevelopment and changes. There are procedures in place to ensure that peoples financial interests are safeguarded. The home does not handle monies on peoples behalf. Records and receipts are maintained of any expenditure incurred such as news papers, hairdressing and chiropody and an invoicing system is in operation which is provided to peoples representatives. The registered manager has implemented systems for ensuring that staff receive regular formal supervision. Information seen demonstrated this and confirmed by members of staff spoken to. Due to the major refurbishment programme in the home extensive risk assessments have been completed ensuring the safety of people living there. A new fire detection system has been put in place and a risk assessment assessment has been completed and approved by the fire authority. Records were in place to demonstrate that regular fire alarm, drills and evacuations have taken place. The manager informed us that new thermostatic mixers have been recently installed and set at the required temperature and that they will be implementing systems for ensuring that the water temperatures will be regularly checked and recorded. Information supplied in the AQAA told us that servicing and maintenance checks of equipment have taken place and recorded. Care Homes for Older People Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 15 It is recommended that the menu provided to people should record that a choice of meals is available. Care Homes for Older People Page 28 of 29 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. 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). 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