Inspection on 12/11/08 for Lindsay Hall Nursing Home

This inspection was carried out on 12th November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lindsay Hall Nursing Home 13/12/06

Lindsay Hall Nursing Home 31/01/06

Lindsay Hall Nursing Home 08/06/05

Lindsay Hall Nursing Home 07/01/05

Lindsay Hall Nursing Home 27/07/04

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: Lindsay Hall Nursing Home 128 Dorset Road Bexhill On Sea East Sussex TN40 2HT     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: Melanie Freeman     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: Lindsay Hall Nursing Home 128 Dorset Road Bexhill On Sea East Sussex TN40 2HT 01424219532 01424222660 info@galleoncare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ms Lynda Foster Type of registration: Number of places registered: Galleon Care Homes Limited care home 38 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia Additional conditions: The maximum number of service users to be accommodated is 38. 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: Dementia (DE) Mental disorder, excluding learning disability or dementia (MD). Date of last inspection Brief description of the care home Lindsay Hall is a Care Home providing nursing and personal care and accommodation for 38 older people with dementia. It is owned by Galleon Care Homes Ltd, which was purchased in April 2008 and became part of Titleworth Healthcare Ltd Group along with the two sister care homes within East Sussex. The home is situated in a quiet residential area of Bexhill-on-Sea close to local shops, churches, pubs and other community facilities. The building is a large, spacious home, providing a light and airy Care Homes for Older People Page 4 of 29 Over 65 0 0 38 38 Brief description of the care home positive environment for its residents. There is a lift in the premises to reach all three floors and has assisted bathing equipment and hoists to assist transfer. There is a large garden to the rear which is accessible to residents and car parking for visitors at the front of the building. Copies of inspection reports and the homes Statement of Purpose are made available on request. Fees charged as from 1 April 2008 range from 513 pounds to 675 pounds per week. Additional charges are made for hairdressing, chiropody, toiletries, newspapers and outside activities such as visits to the theatre. Intermediate care is not provided. 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: The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term service user to describe those living in care home settings. For the purpose of this report those living at Lindsay Hall will be referred to as residents. This was a key inspection that included an unannounced visit to the home and follow up contact with residents representatives and visiting health and social care professionals. This unannounced inspection was carried out over 7 hours on the 12 November 2008. A brief tour of the premises was undertaken and a range of documentation was Care Homes for Older People Page 6 of 29 reviewed including the homes statement of purpose and service users guide, preadmission assessment procedures, the systems in place for handling complaints and protecting residents from harm, staff recruitment files, quality assurance systems and some health and safety records. The care documentation pertaining to three residents were reviewed in depth and the inspector ate a midday meal in the dining room with a group of five residents. Two visitors were spoken to and three staff members were interviewed informally. The required Annual Quality Assurance Assessment (AQAA) was completed and returned prior to the inspection visit and information from this has been used to inform this report. At the time of compiling the report, in support of the visit, the Commission received survey forms about the service from seven residents (completed with the help of family members)and seven staff employed at the home. What the care home does well: What has improved since the last inspection? What they could do better: The procedure followed with regard to admitting any resident to the home must ensure a suitable assessment is completed by a competent person, before admission. This will ensure that those residents that are admitted to the home can have all their care needs met. The care documentation needs to be improved to demonstrate that residents or their representatives are involved in planning the care to be delivered. Social care plans need to be established to provide clear guidelines to care staff. Lindsay Hall has a high ratio of bedrooms in the home that are used as shared Care Homes for Older People Page 8 of 29 accommodation. The use of these rooms needs to be in accordance with residents choices, compatibility and safety. The assessment process used to ascertain this must be documented. The communal space available in the home needs to be improved to ensure it is suitable and sufficient to meet the needs of all residents. Ensuring they are not isolated, can meet people in private, eat in a dining room and spend time in a sitting room if desired. The recruitment procedures must be improved to ensure all the required checks are completed, and relevant documentation is held on file. This will ensure safe recruitment practice is followed at all times, and in turn safeguard residents living in the home. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents and their representatives are provided with information about the home in order to make an informed choice about whether to live at the home. The admission procedures ensure that all prospective residents that are to be permanent placements are fully assessed by a competent person before admission, and are assured that their needs can be met by the home, this however is not the case for all residents who have lived in the home before. Intermediate care is not provided at Lindsay Hall. Evidence: The home has a service users guide and statement of purpose which is displayed in the front entrance area of the home . These are held in a manual that also contains a copy of the last key inspection report and Annual Service Review (ASR) completed Care Homes for Older People Page 11 of 29 Evidence: since the last key inspection. Each resident is provided with a copy of the service user guide on admission to the home. Although the statement of purpose and service users guide were informative and provided useful additional information about advocacy and financial advice. It needed to be updated to reflect the change of the homes ownership and to ensure it contains all the required information. For example it should record the number and size of all rooms in the home. This was discussed with the registered manager. An assessment of the admission process followed included the review of the documentation relating to the last two admissions to the home. This confirmed that those residents that are admitted to the home are subject to a full assessment prior to admission undertaken by the registered manager. This process is thorough taking into account the individuals physical and mental health needs and is followed with a letter to the prospective resident or their representative confirming that the home is able to meet the assessed needs. It was however noted that a resident known to the home from respite admissions, did not have his needs re-assessed prior to re-admission to the home. This shortfall was discussed with the registered manager who confirmed that the admission process would be improved to ensure any people being re-admitted prior to admission. The pre-admission documentation is full and used as to ensure the home has all the necessary equipment and skills to meet the identified need before the resident is admitted. 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. Individual plans of care set out residents needs and care is delivered in such a way that promotes and protects the residents privacy and dignity. With residents health care needs being supported by community resources as necessary. Systems are in place for the safe storage and administration of medicines. Evidence: The care documentation pertaining to three residents were reviewed in depth as part of the inspection process and each of these residents were seen during the inspection visit to the home. Following admission a full assessment is completed and this is used to generate comprehensive plans of care, which identify specific health, personal and some social care needs. A separate file contains the social assessments completed by the activities co-ordinator that includes information from the family around the individuals likes, dislikes, hobbies and past lifes. Social care planning in response to identified needs, interests and preferences are not however followed through to the plan of care and this was raised with the registered manager who said that this would be addressed. Care Homes for Older People Page 13 of 29 Evidence: Risk assessments are completed and regularly updated in respect to a number of areas, including moving and handling, risk of pressure sore development, nutrition and the use of call bells and bed rails. These risk assessments are reflected in and are used to inform peoples individual plans of care. During the inspection visit it was noted that specialist equipment is used as required, although pressure relieving mattresses used for those residents at risk, do not have information about what mattress is being used or on what setting. This was discussed with the manager who agreed to record this specific information within the care documentation. Staff have recently implemented individual mental capacity assessments on all the residents. Base line observations are completed regularly to monitor changing health needs, and the documentation recorded community health care professionals input into care when contacted. Daily records are maintained and provide a chronological record of residents activity, wellbeing and medical condition. On the whole the plans of care were full and gave clear instruction to the care staff on how an individual residents care needs are to be met. They did not however record residents or their representatives involvement and agreement to the plans or any evidence that they are involved in the evaluation and review of the care provided. All feedback from visitors and visiting health/social care professionals was very positive about the standard of care provided at Lindsay Hall. Comments received included this is a very good and caring home I am very happy with the care I have been very impressed with the care at this home I really Like the way that the home treats residents individually, taking into account not only physical, but behavioral needs, even when needs are complex. Observation demonstrated good practice was being followed in respect of the medicine administration and registered nurses administer all medicines. Appropriate policies and procedures are in place.The storage facilities include a separate medicines rooms and a trolley that enables medicines to be administered directly to the resident. Records examined were found to be accurate and clear. It was however noted that some creams found in residents rooms were not labeled correctly and the manager advised that she would address this matter. Some residents are also prescribed medicines on an as required basis and individual guidelines need to be provided so that residents receive medicines as they need them. An example of this was the use of Oramorph for one resident and the use of other pain killers in the home. Residents were seen to be well dressed and were being addressed in accordance to their recorded wishes. The relationship between staff and residents was seen to be respectful and inclusive, both responding well to each others company. When care needs are being attended to this is completed in privacy. It was however noted that there is a high ratio of shared Care Homes for Older People Page 14 of 29 Evidence: rooms in the home, with over half of the occupancy of the home being in a shared room. Although the manager was confident that residents were only accommodated in shared rooms if this was appropriate to their individual needs, there was no evidence that the resident or their representative had been consulted, or that the compatibility of residents sharing had been assessed. All shared rooms have privacy curtains and the AQAA recorded that these are to be reviewed to ensure they are placed in the best position to promote privacy. In addition it was noted that the communal space does not allow for some residents to be seen in private. 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. Links with friends, relatives and the community are encouraged and choices made are respected. Residents receive a wholesome and appealing diet. Evidence: As previously mentioned in this report social care plans need to be provided to promote an individual approach to residents interests and preferences. The lifestyle within the care home is kept as flexible as possible to reflect the varying needs of the residents living in the home. There is a full time co-ordinator that works with support between three local homes within the Organisation. The majority of activities for the residents are one to one due to their mental health needs, however the residents do have the opportunity for group outings and activities/entertainment in the home. The home has recently held a French themed day and photographs seen of this event showed how much staff and residents participated and enjoyed the day. During the inspection visit staff were seen to be engaging with residents playing games and reading books.Two relatives commented on the activities in the home and said I sit in, if there is music etc guitar concerts etc, which my husband really enjoys Care Homes for Older People Page 16 of 29 Evidence: My husband has in the past enjoyed lots of the entertainment that is put on for residents. During the inspection it was noted that some residents spend their day in their rooms and staff spoken to said that the reason for this in some case was due to the fact that when residents were together in the communal areas this caused antagonism. This leads to residents being isolated. One visiting professional commented on this isolation particularly on the lower ground floor but did confirm that staff did maintain a contact with these residents. Discussion with the registered manager confirmed that the lack of communal space that can be used flexibly did limit who could use this facility. Visiting is very much encouraged and seen as an important positive for the home with no restrictions being placed on it. Contact with visitors confirmed they felt comfortable to visit anytime. Comments received included whenever we visits we are always offered tea or coffee and this comes on a beautiful laid tray with cake or biscuits As a visitor I am always warmly welcomed and offered a drink. A visiting professional said how open and honest the staff were when she visited. Choices when ever possible are promoted and responded to. This was very evident around the meal time when residents were invited to make choices. The meal eaten with the residents was well presented and apetising. The variety available was very good and staff ensured that an alternative food was provided to those residents not eating, including small sandwiches and extra puddings.Staff were seen to deal with residents win a sensitive way and with a good understanding with regard to their individual needs and behavior promoting their independence as much as possible. Only five residents ate in the dining room and the space available did not allow for many more residents to eat in this area in comfort. The menus demonstrated a well-balanced and nutritious diet. The menus rotate on a four weekly basis and offer a variety of meals. Feedback from surveys and from people spoken with was very positive about the food and the way the staff focus on the importance of a good diet. My husband did not eat when he first arrived the carers have time to feed him and the food is very good and it is good to see my husband eat everything on his plate Good with encouraging residents to eat never give up hope with him when they are not eating. 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. People are confident that any complaint would be listened to and responded to appropriately. Staff training and information in the home ensures that any Safeguarding Vulnerable Adult issue would be responded to appropriately when identified. Evidence: The home has a comprehensive complaints procedure although this needs to be updated to reflect the change of ownership. People spoken to were all confident that the staff and management in the home would listen to any concern, and respond to it effectively. The manager confirmed that the home had not received any complaint since the last inspection. The home has relevant policies and procedures on the protection of vulnerable adults although these need to reflect the new local policies and procedures on Safeguarding Vulnerable Adults. Staff training is ongoing with two staff recently attending training provided by Social Services. Staff recruitment files confirmed that staff have a Protection Of Vulnerable Adults (POVA) check completed along with a Criminal Records Bureau check (CRB). Care Homes for Older People Page 18 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 adequate 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 well maintained, clean and safe home. There is not an adequate provision of communal space to meet the individual needs of all residents in the home. Evidence: Lindsay Hall is a converted premises that is situated in a residential area of Bexhill. A tour of the home confirmed that the building is well maintained although the furniture, fixture and fittings are in need of attention. Discussion with the manager and a representative from Titleworth Healthcare Ltd confirmed that this had been recognised and is to be addressed. The home has one communal room that is used as a sitting room and dining room on the ground floor, there are also small seating areas in a hall way and landing area. The provision of flexible communal space to meet the differing needs of residents has been raised in previous inspection reports. It was however clear at this inspection that the communal space is not adequate. Some residents were found to be sitting in their rooms all day, this was said to be not only of their own choice but to prevent the agitation caused when some residents are in the same room together. It was also noted that a high ratio of rooms in the home are for shared occupancy. These are occupied by residents that may not have the ability to make a positive Care Homes for Older People Page 19 of 29 Evidence: choice to do so, and there was no documentation to confirm how a decision was made to share a room or who was involved in this decision making process. The manager did confirm that consideration is given to residents compatibility. Clearly when rooms are shared the management need to be mindful of not only the choices and compatibility of residents, but the environmental constraints. Many residents have a high dependency requiring specialist equipment and suitable space needs to be available to ensure residents and staff safety. Residents accommodation is found on the three floors and a shaft lift provides level access throughout the home. A patio and garden area is accessed from the lower ground floor. The home was found to have a good standard of cleanliness in most areas although some furniture was difficult to keep clean due to its condition. The home smelt clean and fresh. Most residents have photographs and some possessions in their rooms but overall the rooms looked rather impersonal, this was raised with the manager for further consideration and improvement. The home has suitable arrangements in place to promote good infection control practice and a survey recorded All our relatives who visit say how clean and comfortable the home is. The home has a well managed laundry that is staffed every day and a sluice room is provided on each floor. It was also noted that protective gloves and aprons were readily available throughout the home, promoting good infection control practice. Care Homes for Older People Page 20 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. Staffing numbers and skill mix provides a competent and well-motivated staff team that meets residents health and personal care needs. The homes recruitment practice needs to be improved to ensure all the necessary checks are completed, and all the necessary documentation is held on file for all staff to safeguard residents. Evidence: At the time of this inspection visit the home was occupied by 32 residents and staffing levels observed were found to be appropriate to meet the needs of residents. However feedback from staff surveys indicated that staffing levels are not always adequate at times of high activity. This was raised with the manager for her to review the staffing provision and to ensure suitable levels are maintained throughout the day and night. Observation throughout the inspection visit confirmed that staff worked well together supporting each other and providing help when needed. Staff spoken to confirmed that the team spirit in the home was good, with many of the staff having worked in the home for many years. A staff survey recorded its excellent team work. A visiting professional also commented on the stable staff team. All feedback about the staff was very positive and staff were found to be kind and well Care Homes for Older People Page 21 of 29 Evidence: motivated about providing a good standard of individual care . Comments received included The staff are the most wonderful team of people you could ever get, they are kind supportive and caring the staff are very kind and caring the staff are very good to both of us. Staff training has been given a high priority in the past and the Annual Quality Assurance Assessment (AQAA) returned by the home confirmed comprehensive induction process for new staff members, which is in line with the Common Induction Standards, and that 70 of care staff have completed a National Vocational Qualification in care at level 2 or above. Staff training is being re-established since the homes purchase and on the day of this visit a safe moving and handling training session was being provided. On the whole feed back from staff was positive about the training provided although there was an indication that further specialised training is needed for example in respect of dementia and challenging behavior. The recruitment files pertaining to three staff were reviewed as part of the inspection process. Although records examined confirmed that application forms are completed along with the required Criminal Records Bureau (CRB) and POVA checks, there were a number of shortfalls that included, two references are not sourced for all staff employed, photographs of staff are not retained in the home, not all staff had evidence of a health check or the right to work in this country The manager was advised of these shortfalls and agreed to address them. She was also advised that information gained as part of the recruitment process needs to be risk assessed if necessary and clearly recorded as to decisions made to employ an individual. Care Homes for Older People Page 22 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. Residents benefit from a qualified and competent manager who takes into account residents views to improve the quality of care and services in the home. Residents financial interests are safeguarded and systems are in place to protect the health, safety and welfare of residents and staff. Evidence: The home manager is an experienced dual registered general and mental health nurse with more than 20 years experience in elderly care. She has been manager of Lindsay Hall for 10 years during which time she has provided a stable and supportive environment for both staff and clients. She also holds the Registered Managers Award and attends regular updating to maintain her skills. She is approachable and makes herself availble to residents and staff. All feedback about the managment of the home was positive, one staff survey recorded I think the management do a wonderful job. The managment structure is strong with clear lines of accountability. Care Homes for Older People Page 23 of 29 Evidence: The duty rota confirmed that the manager is included in the numbers to provide direct care for some shifts and this reduces the time availble for management duties and should be reviewed in line with her role and her changing responsibilities, that are to include more finacial managment at a local level. The home has various systems in place to review the quality in the home and this includes the use of questionnaires that gather information from residents and other stakholders. These have not been used this year and the manager siad that this was to be completed. Monthly reports are recorded by a designated person from the Organisation and are completed as required. The AQAA was found to be well completed and used as a quaility monitoring tool. Regular staff meetings and resident/relative meetings are held and records of these are kept. The home does not take any responsibility for any of the residents finances and in most cases residents families deal with them. If any money is spent on behalf of a resident this is included in the monthly accounts. Discussion with the staff and evidence within staff surveys confirmed that staff feel well supported and comments included the staff and management are very helpful at all times. It was however identified that staff would appreciate supervision directly with the manager on occassions. This was raised with the manager to address. This is clearly important to staff at this time with recent changes to the homes ownership. The home has a full time maintenance man who has worked in the home for a number of years and has a good understanding of all health, safety and maintenance issues. Records seen confirmed that regular risk assessments are completed along with regular safety checks. Care Homes for Older People Page 24 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 25 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 3 14 That the registered person 22/12/2008 ensures that a competent person assesses all prospective resident before admission. A copy of this assessment is obtained by the home when this is not completed by the home to inform the admission process. This will ensure that only those residents whose needs can be met by the home, are admitted. 2 7 15 Plans of care are composed and reviewed with input from the resident and or their advocate, unless the offer is declined. This will ensure that the care provided is in accordance with each residents wishes. 02/02/2009 3 20 23 The communal space in the home is improved to ensure an adequate provision of 01/06/2009 Care Homes for Older People Page 26 of 29 sitting, recreational and dining space is available separate to the resident,s private accommodation. This will ensure that residents are able to spend time in different areas of the home according to their own preference, and allow them to see people in private if they want to. 4 23 12 That shared rooms are only 01/01/2009 used when appropriate and in accordance with residents choices, compatibility and safety. The assessment process used to ascertain this, must be documented. This will ensure that residents preferences, privacy, choices and safety are taken into account with regard to the use of shared rooms. 5 29 19 The registered person must ensure that the necessary checks and records are completed and held in respect of each employee. This must include two suitable references. This will ensure only those staff suitable to work in the home are employed. 01/01/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. Care Homes for Older People Page 27 of 29 No. Refer to Standard Good Practice Recommendations 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). 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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