Inspection on 25/09/08 for Kilkee Lodge Residential Home

This inspection was carried out on 25th September 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Kilkee Lodge Residential Home 10/10/06

Kilkee Lodge Residential Home 13/12/05

Kilkee Lodge Residential Home 17/05/05

Kilkee Lodge Residential Home 21/09/04

Kilkee Lodge Residential Home 19/03/04

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 29/01/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Kilkee Lodge Residential Home 297 Coggeshall Road Braintree Essex CM7 9ED     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: Diane Roberts     Date: 2 6 0 9 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Kilkee Lodge Residential Home 297 Coggeshall Road Braintree Essex CM7 9ED 01376342455 01376342466 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Paula Jean Winestein Type of registration: Number of places registered: Kilkee Lodge Care Homes Limited care home 80 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 80 persons) Two people, over the age of 65 years, who require care by reason of dementia, whose names were made known to the Commission in January 2005 Date of last inspection Brief description of the care home Kilkee Lodge is a purpose built home for older people. All rooms are single with ensuite facilities. The home is built on two floors with a lift. It is able to meet the needs of people that require assistance with personal care and mobility. The home comprises of several lounges, dining and conservatory areas. There is a large, secure courtyard, which is decorated with tubs and provides seating for residents. The home is situated near to Braintree town centre, local amenities, shops and GP surgery. The fees for the Care Homes for Older People Page 4 of 29 Over 65 2 80 0 0 Brief description of the care home home are from £482.00 to £536.00 a week. Additional costs include personal items, hairdressing and chiropody. 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: We visited the home over two days and met with the manager and her deputy on both days. On one day it was possible to meet briefly with the proprietor. During our time at the home we talked with four residents, four members of staff, five relatives and two district nurses. We sampled and reviewed records that related to, for example, care provision, medication administration, staff recruitment and training, activities, meals, complaints and the building itself. In addition to this the manager completed a self assessment prior to the inspection, called an Annual Quality Assurance Assessment ( AQAA). This tells us how the manager thinks the home is running and what they do well and what they could do better. This assessment is referred to through the report. Prior to the inspection, we sent feedback surveys to the home for residents and staff to Care Homes for Older People Page 6 of 29 complete to give us their views, but we had a limited response. We feel that this is linked to the fact that the home seeks feedback very regularly from residents and relatives already. We felt that the feedback the home already had was objective and sound and we have also used this as evidence in our report. 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 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 9 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can be assured that they will have sufficient information about the home prior to admission and that they will be appropriately assessed to ensure that the team at the home can meet their needs. Evidence: The manager has a system in place for the pre-admission assessment of prospective residents. Either the manager, her deputy, or if required, her senior care staff undertake these assessments. Assessments were reviewed and found to have been comprehensively completed and the assessment tool contains all the required information for the manager to make an admission decision. Should a review of the assessment tool take place it is recommended that a more person centered approach be taken, so this will help the team lead into person centered care planning. Assessments, where appropriate were accompanied by social services referral information which backed up the assessment. Care Homes for Older People Page 10 of 29 Evidence: Residents spoken to said that they had settled in well and that they has been made to feel welcomed by the staff at the home. Residents also confirmed that they had seen the service users guide and that they had had an opportunity to visit the home prior to admission. Discussion with new residents also showed that they were well informed about the home and the services offered. The manager in her AQAA states that residents have relevant information available to them to enable them to make the right choices regarding where they would like to live. Care Homes for Older People Page 11 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. Residents can be assured that their care and health needs are generally met but not in a fully person centered way. Evidence: The manager has a care planning system in place. Care plans reviewed showed that residents needs had, on the whole, been identified well and that detailed information was in place to guide staff as to what support was needed. However, the care plans were not very person centered and contained limited information regarding the individual and their preferences/diversity etc. This was discussed with the manager as an area for development. Although some care plans were in place, more consideration also needs to be given to care planning for residents who require ongoing pain relief and for those with identified mental health needs, such as people with a history of depression or those bereaved. The manager in her AQAA states we provide comprehensive care plans for each resident and these are reviewed by senior staff. The care plans in place were seen to be up to date and good meaningful reviews had been written. The manager uses a monthly review checklist system. Also in place was Care Homes for Older People Page 12 of 29 Evidence: a very useful regular key worker review which also evidenced that staff were discussing residents care plans with them. Relatives spoken to said I have seen my relatives care plan and signed it. Daily notes are maintained but the majority of these did not reflect the resident in a person centered way or the care provided and they often stated full care given. This needs to be addressed to evidence the care provided to residents and thewir wellbeing in a fuller way. Appropriate risk assessments were seen to be in place that covered a range of topics, including manual handling and nutrition. These were reviewed monthly but staff need to be aware that they may need to update these more often, for example following a fall. Some residents are monitored with regard to their fluid intake. These were reviewed and it was disappointing to note that in one case, staff were observed to have completed the intake record before the resident had actually drunk the drink. This can give a false account of the true fluid intake. The manager was made aware and needs to address this issue. From records and discussion with staff, residents health care needs are being met. Residents have benefited from the district nursing staff basing a clinic at the home and the district nurses have been working with the care staff to increase their skills and knowledge base. District Nurses spoken to felt that the staff team knew the residents well and referred appropriately to them, especially with regard to residents at risk of developing pressure areas. Records showed that residents see their GP in a timely manner and also have access to other health care professionals such as chiropodists and opticians etc. Records also show that residents attend hospital appointments and where required, the manager sends an escort with them Records showed that whilst residents were being weighed, this was often inconsistent and therefore would not be an adequate monitoring check for some residents in the home. It was again observed that residents living in this home spend a significant amount of time sitting in wheelchairs rather than a more supporting lounge chair. Whilst it is acknowledged that residents do go back and forward to activities, staff need to seat them properly to ensure that they move during the day and improve their circulation etc. When speaking to residents and relatives, two commented on this saying my relatives spends too much time in a wheelchair and I spend all my time in a wheelchair. The manager needs to review this and ensure that this is in the best interests of residents and not the staff team. Comments from the managers monthly feedback sheets, from residents and relatives, on the standards of care at the home include the care side of things is alright, sometimes you can wait too long for the buzzer to be answered, the standard of care is very good, good standards of care but I would like to do some of my own chores like put laundry away, everything is to a high standard, very good standards of care with all needs catered for, good standards of care, I am aways kept well informed and my relatives needs are well catered for, standards of care are usually very good, Care Homes for Older People Page 13 of 29 Evidence: carers are very helpful and very good standards of care indeed. Several residents and relatives commented on the lack of staff. This could relate to deployment and staff taking breaks as discussed in section 6 of this report, which the manager has been asked to review. Medication systems at the home were checked and found to be in good order. Medication administration sheets were seen to be clear and records were up to date. Medication was checked in correctly to the home and returns are completed. As required medications are accounted for, as to why they have been given, and it was positively noted that some residents are self medicating and up to date risk assessments for those people were seen to be in place. Where residents had been refusing medication, records showed that they had been referred to their GP for review. Staff should be dating liquid medication, when opened, for expiry and audit purposes and whilst controlled medications were properly accounted for, the return of any excess items needs to completed in a timely manner. Interaction between the staff and the residents was seen and heard to be appropriate, friendly and caring. Residents were observed to be well groomed and their individuality respected. Care Homes for Older People Page 14 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Not all residents can be assured that their social care needs will be met in the home, but they do benefit from a resident led staff team giving an individual approach to care provision. Evidence: On discussion with residents, they confirmed that they had choices with in the routines of the day and comments included I do what I want when I want and I go to bed when I want, usually quite late. On discussion with care staff, they talk about the residents and the routines of the day in a very resident led way. They demonstrated that they know the residents and their preferences and individual routines well, but this valuable person centered information is not always reflected in the care plans. Residents care plans and individual activity records were reviewed in relation to the social side of care. Care plans contained limited person centered information and life histories had not always been completed. Activity records show some basic preferences but no real assessment of need or social history. The team need to develop these assessments so they can ensure that they meet the needs of the resident in a more person centered way that appreciates their diversity and individual Care Homes for Older People Page 15 of 29 Evidence: choices, outlining skills they would wish to develop or retain, promoting independence, self worth and limiting isolation. This would be especially helpful to staff providing one to one time- enabling this to be more resident focused. The manager in her AQAA states that each resident has an activities plan, likes and dislikes for leisure activities are discussed and taken into consideration. Evidence shows that this is not the case for all residents in the home. Records of completed activities were limited or blank in some cases, for individual residents and demonstrates no input for long periods. The manager in her AQAA states that we provide one to one activities for people that do not wish to join in group activities. The evidence in the home does not fully concur with this. Despite the shortfall in assessments and recording, it is clear that the activities team do provide a service that meets the needs of a core of residents in the home. The team is well resourced and two officers work during the week and also prepare good quizzes etc. for residents to complete at the weekend. A regular group of residents attend and activities include colouring, crafts, word searches, skittles, bingo and ball darts. A full assessment may help to stimulate a wider programme of events to appeal to more people. A programme of activities is produced each week and distributed to each resident, these were seen around the home. Programmmes show that entertainers come to the home as do local church people and residents also enjoy dominoes and films. The programme also shows a you choose session where residents who have attended choose what they would like to do, although the activities officer confirmed that at other times residents can change the programme if they wish. The activities officer said that she sometimes takes residents out shopping and it was clear that she was doing this on the day of the inspection. The staff at the home take residents out using community transport, but this does limit them due to timing restrictions. Recent visits out include a local garden centre. The manager plans to develop activities in the home by providing a games rooms and an arts and therapy room. Residents spoken to commented that I choose not to take part in activities, I spend a lot of time in my room, my key worker is just a name to me, I choose not to take part in the activities and I go to activities every day, there is something on every day - I play bingo, do colouring and quizzes. Comments from the managers monthly feedback includes I dont take part in activities but I do enjoy the singers that come, I really should try the activities people are always offering to take me, very good, excellent. really enjoy them, I would like more music, very good the activities ladies try hard, dont go to any of them it would be nice to go out sometimes. Residents are generally happy with the meal service provided at the home. The chef was observed to be visiting residents and discussing meals and meal choices with Care Homes for Older People Page 16 of 29 Evidence: them. Records showed that residents do choose different things from the choice on the main menu and that they also state portion size. Menus show a good variety of choice, including at breakfast time. The dining rooms are pleasantly decorated and the tables are nicely laid. Residents spoken to commented that the food is fine, its hot and there is a choice, the food is good, sometimes the food is nice and the food is very good, you get a choice, its nice and hot. Comments from the managers monthly feedback include the kitchen does a good job, Im happy with the food, not first class you cant please everybody, meals are not as good as they could be cheap mince and frozen veg, good food, meals I have seen look appitising and well presented, food is very good, my relative enjoys the food and would it be possible to have less frozen food, i.e vegetables and fish. Care Homes for Older People Page 17 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. Residents can be assured that their concerns would be listened to and dealt with appropriately and that, as far as possible, they would be safeguarded at the home. Evidence: The manager has a complaints procedure in place that meet regulatory requirements. This is displayed in the main reception of the home and is also available in the service users guide. Consideration should be given to the format and to making the procedure more user friendly. Both residents and relatives spoken to knew who they would raise any concerns with and the managers quality assurance feedback also confirmed this with comments such as the management team have always been helpful, no problem in speaking with the management of the home and I always get a friendly and helpful response. Since the last inspection the manager has dealt with 4 complaints. Documentation relating to these matters was reviewed and found to be satisfactory with the manager conducting full investigations and keeping good records. The manager has in place policies and procedures on adult safe guarding which staff can refer to. On discussion with staff, they showed an understanding of adult safeguarding matters and how to deal with them. Training records show that there are good compliance levels with staff training on this subject, at nearly 100 . Since the last inspection there has been one adult safeguarding referral at the home and this was dealt with appropriately, with the required agencies involved. The manager needs to ensure that she keeps all the required internal records in relation to these matters. Care Homes for Older People Page 18 of 29 Care Homes for Older People Page 19 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. Residents live in a home that meets their needs and is pleasant and safe to live in. Evidence: A tour of the home was undertaken with the manager. All communal areas were visited along with a number of the bedrooms. Overall the home was seen to be decorated to a high standard and well maintained. The home is also very clean and no odours were noted, the domestic team have good attention to detail. The home has recently been awarded a local authority grant and plans to spend this on improvements to the central courtyard area, providing a pergola and to develop their games room and a therapy room for residents to use. Since the last inspection the proprietor has purchased new dining furniture and new lounge furniture is on order, which includes, chairs, sofas, footstools, coffee tables and soft furnishings such as curtains. The corridors were noted to be very plain and the manager plans to purchase pictures to make these more homely along with the bathrooms which are also plain. The bedrooms are generous in size and all rooms are en suite with a shower. Residents have personalised their rooms as they wish. A maintenance man is employed at the home and records show that staff are good at recording items to be attended to and these are promptly dealt with. Records also show that he undertaken regular checks of water temperatures etc. The manager in her AQAA states that all maintenance issues are recorded and dealt with by our full Care Homes for Older People Page 20 of 29 Evidence: time maintenance man. This concurs with the evidence found. Residents spoken to said that everything is fine with my room, I am happy with my room and I have my telephone and my room is cleaned every day. The managers last quality assurance feedback questionnaire showed that relatives and residents were happy with the fabric of the home and comments included very good, on the whole, very good, decor and furnishing is good, cleanliness good, always smells fresh, the lounge is attractive as is my relatives room and the dining room always looks nice. Where people commented on minor issues, the manager has attended to these. The manager has completed a fire safety risk assessment and on the day of inspection was in the process of reviewing this. Certification in relation to fire safety was reviewed and found to be in good order with equipment maintained and tested and staff fire drill undertaken regularly. Care Homes for Older People Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from a well trained staff team but occasionally their needs may not be met due to staffing levels or the deployment of staff. Evidence: At the current time, the home has a relatively stable staff team. There has been some turnover in the last year and on discussion with the manager, this relates to a wide variety of reasons. Agency staff are rarely used at the home, which helps to give residents continuity of care. The manager currently provides 12 - 14 staff in the mornings and afternoon. The rota shows that extra staff are put on duty, should the need arise, and this concurs with the managers statement in her AQAA which says we call in extra staff for escort duties where possible. At night the manager aims to have 6 care staff on duty. Occasionally this drops to five, primarily at weekends. In addition to this there are two activity officers on duty during the week/daytime and a full ancillary team. Residents comments include sometimes there seems to a shortage of carers and when the home is fully staffed things are OK, when it is short staffed or break times thats a problem. Relatives commented that weekends need better cover and could do with more staff on duty at times. Overall relatives and residents commented that the standards of care in the home were either generally good or very good. The manager needs to review the staffing levels and deployment, staff break times etc. to ensure that the home is covered in relation to residents dependency as Care Homes for Older People Page 22 of 29 Evidence: well as numbers. The manager has also reflected this issue in minutes of meetings with staff as relatives often think, especially at weekends, that the home is short of staff, when it is not the case. The residents benefit from having a care team where over 60 have achieved an NVQ qualification in care and the manager reports in her AQAA that 17 more staff are signed up for this course. Recruitment files were checked at random and found to be in good order with all the required checks and documentation in place, including references and criminal bureau record certificates. The manager has started to use the Skills for Care induction. On examination of the records, it showed that the team were behind in getting these inductions started. For example, staff starting in April 2008 had only just started their full induction in September 2008. This needs addressing and the manager was aware of this shortfall. New staff do attend an in-house induction and work with experienced staff until they are deemed competent. Training records show that overall the level of training provided in the home was very good. Staff have completed statutory training such as manual handling, health and safety and infection control. The manager has also developed a member of staff on night duty who can now train night staff in manual handling. There are odd gaps in the manual handling training, but this should be addressed now a further trainer is in post. In addition to statutory training, staff have also attended study days etc. on sensory impairments, diabetes, nutrition for the elderly, medication, loss and bereavement, dementia awareness, Parkinsons disease and person centered care planning. Staff spoken to confirmed the training provided and said that there is a lot of training provided for staff in this home and I am put forward for a lot of training and I am also doing my NVQ training. Staff have feedback to management that I think that I am offered relevant training and I would certainly ask if I would like any training and the training at Kilkee is very high, although I would like to do another first aid course as the last one was some years ago. The manager in her AQAA states we provide extensive training for all of our staff on a regular basis. Care Homes for Older People Page 23 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. Efforts are made to ensure that the home is run in the best interests of the residents. Evidence: The manager has worked at the home for 11 years and as the registered manager for six years. She has completed her Registered Managers Award and records show that she keeps up to date with her statutory training. Systems in the home are well organised and the required records are available. The manager meets regularly with the staff team and the minutes show that a wide variety of subjects are covered. Staff spoken to said that the management of the home is very supportive of us and there is a good atmosphere in the home and the manager is approachable. The manager has a quality feedback system in the home that is linked to the regulation 26 reports completed monthly by the proprietor. Each month residents, staff and relatives are surveyed for their comments and these were reviewed. They showed a good level of open feedback from all concerned and these had been completed on a Care Homes for Older People Page 24 of 29 Evidence: regular basis, although not always monthly. Once surveys are collated an action plan is developed. The manager also consults with residents and relatives through meetings and minutes of these are available. The manger and her senior care team also audit practices in the home such as medication and care planning. Residents and relatives spoken to said that I think that the home is run pretty well, I am quite happy living here, everything is quite reasonable and its a very good home. Comments from the managers monthly feedback includes the home seems quite well run, all seems efficiently run and the organization of the day to day running of the home appears excellent. A staff supervising system is in place and staff confirmed that this is happening. The manager and deputy manager have a recording system in place and acknowledge that there are still gaps and the new system is developing. No health nd safety issues were noted on touring the home. A random sample of safety and maintenance certification were found to be up to date in good order. Accident records were adequately maintained and followed up where required. The home makes good use of a falls prevention team linked to the local primary care trust. Care Homes for Older People Page 25 of 29 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 27 12 The registered person must ensure that staff respond promptly to the needs of residents. This refers specifically to the call bell system. 07/12/2006 2 36 18 The registered person must 07/12/2006 ensure that staff receive supervision at least six times per year. This standard was not inspected. Care Homes for Older People Page 26 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 1 7 15 Residents assessed care 30/11/2008 needs must have a care plan in place, with particular reference to pain management and general wellbeing/mental health To ensure that residents needs are met in full. 2 8 12 Residents health care needs must be met in relation to fluid intake, weight monitoring and time spent sitting in wheelchairs To ensure that residents health is promoted and care is provided in their best interests 30/11/2008 3 12 16 A review of the social activities provided in the home and how they are organised is needed, including a full consultation with and assessment of residents living in the home and the records maintained. 31/12/2008 Care Homes for Older People Page 27 of 29 To ensure that the social care needs of all residents in the home are met as far as possible. 4 27 18 A review of the staffing level 30/11/2008 and staff deployment is needed, also giving consideration to staff break times. Residents need to be assured that there are sufficient staff on duty at all times to meet their needs. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 3 When the assessment tool is next reviewed, consideration should be given to adopting a more person centered approach that therefore leads into person centered care planning. Person centered care planning needs to be developed further in the home so that residents care needs are met in an individual way with their wishes and preferences taken into account. The complaints procedure should be reviewed to make it more user friendly for residents. Continue to develop the staff supervision system. 2 7 3 4 16 36 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 © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. 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