Inspection on 31/01/09 for Lord Harris Court

This inspection was carried out on 31st January 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lord Harris Court 31/01/07

Lord Harris Court 30/06/06

Lord Harris Court 17/01/06

Lord Harris Court 02/08/05

Lord Harris Court 22/02/05

Lord Harris Court 05/07/04

Lord Harris Court 20/01/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

Extracts from inspection reports are licensed from CQC, this page was updated on 20/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Lord Harris Court Mole Road Sindlesham Wokingham Berkshire RG41 5EA     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: Robert Pettiford     Date: 0 1 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 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: Lord Harris Court Mole Road Sindlesham Wokingham Berkshire RG41 5EA 01189787496 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Royal Masonic Benevolent Institution The registered provider is responsible for running the service care home 90 Name of registered manager (if applicable): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 Over 65 90 old age, not falling within any other category Additional conditions: 0 The maximum number of service users who can be accommodated is: 90 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) Date of last inspection Brief description of the care home Lord Harris Court is Royal Masonic Benevolent Institution Home that provides accommodation and care for up to ninety service users over the age of sixty-five years of which some may require nursing care. Lord Harris Court is situated in Sindlesham and is close to local shops, supermarkets and train station.There is an in-house shop one day a week, and transport in the homes mini bus to local shops for those more Care Homes for Older People Page 4 of 29 Brief description of the care home mobile. There are a number of garden areas and 3 large lounges for the residents and their visitors to use and a large dinning room. The home has a a wide ranging activity programme, a library and hairdressing facilities. Fees are available from the home. 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 inspection took place at 9:00AM on 31st January and 1st February 2009 We agreed and explained the inspection process with the manager. The focus of the inspection was to assess the home in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Older Persons. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. We used a varied method of gathering evidence to complete this inspection, pre inspection information such as discussion and correspondence with the registered Care Homes for Older People Page 6 of 29 provider/manager was used in the planning process. This was to support us to explore any issues of concern and verify practise and service provision. The home had completed an annual quality assurance assessment questionnaire (AQAA). This provided us with information relating to What the agency considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. The judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the Commission to be able to make an informed decision about outcome areas. Further information can be found on the Commissions website with regards to information on KLORAs and AQAAs. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. Other areas viewed included risk assessments, pre-admission assessments, rotas, and training records. In addition an environmental tour took place. We identified several residents for case tracking (a review of the level of care and support needed, and if it is being provided in a way that treats them with respect and dignity). What the care home does well: What has improved since the last inspection? What they could do better: The inspection identified several areas that were in need of being addressed. The management of the home has recognised the shortfalls and has indicated a willingness to work with the Commission to ensure that any shortfalls are addressed. The main areas that were identified were :In the care plans viewed there was sufficient detail and guidelines in respect of the support needed to meet their needs. Although not all the care plans were regularly updated. The Commission is of the opinion that sufficient care staff were on duty to support Care Homes for Older People Page 8 of 29 residents with their needs. However the manager was requested to review staffing to ensure sufficient management cover is available at weekends. Due to the size of the home and some of the residents complex needs it was recommended by the Commission that the home considers having management cover available seven days a week to ensure that staff receive support and direction. The manager in response to our concerns confirmed that it had already been identified that additional cover was required at the weekends and that she is taking steps to the review management levels and provide extra cover. Shortfall were noted with regard to basic courses being completed by all staff. Namely first aid, food hygiene and infection control. No evidence was additionally available that staff have recieved training in Dementia care. 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. Residents can feel 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. Intermediate care is not provided. Evidence: Residents can be confident that 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 where possible and have got full, clear,accurate and up to date information about the home. The AQAA states the home ensures that whenever possible that the prospective residents visit the home and we discuss with them and their families what their needs are. They address any concerns that they may have Care Homes for Older People Page 11 of 29 Evidence: and ensure that the new residents room is correctly equipped prior to their arrival. All residents are given a welcome pack (Service User Guide) containing the complaints policy when they arrive, and the management team have an open door policy so that they are available to listen to any problems should they arise. Records held showed that residents have an assessment, which identifies their individual needs prior to or on admission to the home. The information is provided by the residents, their families and health / social care professionals. The assessment focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet needs of the individual. The AQAA states all residents are encouraged to follow their own religious beliefs and we have residents and staff from several religious backgrounds. All staff are instructed during their induction and NVQ programmes to respect all the residents whatever their religious belief, race,gender identity, disability and sexual orientation. The The Royal Masonic Benevolent Institution has appointed a Training Manager who will be ensuring that all staff have up to date training in equality and diversity. 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. Residents benefit overall from having individual plans that identify their physical and medical needs, but not enough detail was given to ensuring that plans of care are regularly updated and reviewed. Residents can feel fully confident that they are fully supported with their healthcare needs and that their wellbeing will be protected by the homes policy and procedures with regard to the handling and administration of medication. Residents can be confident that they will be treated with respect and dignity and their rights to make decisions about their lives and are respected as they wish or their capacity allows. Evidence: We viewed and discussed with the manager the care records relating to five residents at the home. In the care plans viewed there was sufficient detail and guidelines in respect of the support needed to meet their needs. Not all the care plans were Care Homes for Older People Page 13 of 29 Evidence: regularly updated however on the examples seen. Daily notes did not follow guidance issued by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting in that they were not accurately timed and signed, with the signature printed alongside the first entry and not include gaps. The quality of the care plans viewed within the nursing unit were however regularly reviewed detailed and updated. The management team need to ensure that staff revising plans of care within the residential side of the home have the time and training to carry out the task. Whilst it was accepted through discussions with residents, and feedback from relatives they were happy with the standards of care received and generally had a high opinion of the home, the care plan documentation suggested otherwise due to lack of review. Evidence was available that residents or relatives where possible were involved in drawing up personal care plans in the documentation and that they are consulted in reviewing and amending such care plans as their capacity allows. Some of the care plans viewed were signed by a resident or a representative. However this was not the case for all care plans viewed. The inspector viewed a sample of care records and specific health care records relating to several residents. Records viewed confirmed that residents had access to a range of health care inputs as and when required and part of regular health checks. The home also ensures residents have access to Dentists and Opticians etc. The home also ensures that residents have access to their chosen Doctor for medication reviews and health check ups (if possible), in addition to identified specialist health care input. The inspector visited the home at 900AM. During the inspection we noted that residents were seen making choices about their lives and were seen to be part of the decision process where possible. A relaxed atmosphere was noted with the residents interacting with staff. We also had the opportunity to speak with many residents who expressed satisfaction with the care offered and given. We had the opportunity to join some of the residents for lunch. During this time it gave the opportunity to explore with the residents spoken with their experiences of living within the home. All spoken with expressed satisfaction of living within the home and the respect and dignity they were treated with. Some concerns were raised about the choices at meal times. This information was passed on to the manager. We also spoke to the relatives of one couple living within the home. They felt very happy with the home and the level of support offered. They liked the home and said their relatives Care Homes for Older People Page 14 of 29 Evidence: enjoyed the activities offered and the standard of the food. The inspector viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of PRN/s Required Medication. The home has two clinical / medication rooms one on the nursing wing and one on the residential. Medication cabinets and trolley were evident in a dedicated room. The medication record sheets observed, were completed correctly. However PRN medication was not written up on the back of the sheet and it was unclear in some instances whether some PRN medication was being used as a regular medication. PRN protocols were not written up for each PRN. Such guidance provides Nurses and care staff with an agreed protocol / guidance to ensure that any clinical decisions to give PRN is done in a consistent manner by all Nurses/ care staff. The Manager was requested to review some of the residents medication with their Doctor to ensure that PRN guidance is in place. The disposal of medication brought to the Commission some concerns on how the throughput of medication could be audited to a high standard. It was the view of the Commission that the current system could be open to abuse. We commented on the homes drug disposal policy and asked the manager to review to ensure it meets with current guidance to ensure that it complies with The Royal Pharmaceutical Society of Great Britain (RPSGB) 2007. The Handling of Medicines in Social Care, this provides professional pharmaceutical guidance for staff working in every area of social care to improve the safety and quality of medicines. No requirement has been made at this time as the Commission is confident that the shortfalls would be addressed. 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. Residents social and recreational interest and needs are provided for with a range of activities organised and are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. Residents nutritional needs are met by a home that Sees food as something to be enjoyed and required to maintain good health. Evidence: The AQAA states residents are encouraged to participate in all activities, and go out with their families whenever they wish to. The home provides a range of activities to suit as many people as possible, and it is their choice whether they attend or not, the carers do inform every resident of the activities of the day, and they are promoted on the noticeboards. A new digital screen is to be fitted in the reception area that will display activities for the day and week and also the weeks menu. The residents are able to go out to shop in the homes mini bus. There is improved access to activities with a second activities coordinator being employed bringing new ideas. Residents are encouraged to take park in a variety of Care Homes for Older People Page 16 of 29 Evidence: activities as their interest and capacity allows. The home has sought the views of residents and considered their varied interests and abilities when arranging activities. The activities and plans are resident focussed, regularly reviewed. Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them to have a drink or a meal. Residents can choose to entertain visitors in their own rooms or perhaps a lounge or garden areas. The AQAA states that mealtimes are very important to residents and they are encouraged to socialise and sit with friends. There are some residents who like to eat in their own rooms and this is accommodated.The catering is provided by a contract caterer Medirest. There are regular meetings with the residents, staff and cateres.They enjoy celebration meals either in the dining room or as a private party with relations and friends. Residents can plan to have relatives for meals on any day. We viewed residents eating their midday meal. From observation, records viewed and comments made by residents it was evident that residents had been offered a choice of menus that met their dietary needs and individual preferences. The food provided for the residents was found to be varied and nutritious and of a good quality. The chef meets the residents regularly to ensure she has feedback about the meals provided. During the inspection food storage areas were viewed along with quantity and quality of food. A good variety of food was found including meat, vegetables tins and fresh fruit. The kitchen and storage areas were seen to be well organised and clean.The chef stated the Kitchen meets with the requirments of the Environmental Health Officer of the local council. 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. The home has a effective complaints system in place and residents and families are aware of its contents. Residents are protected by adult protection policies and procedures. Evidence: The home had a written complaints procedure, which was seen in the foyer. Residents spoken with felt free to voice their concerns. The home has received 16 complaints in the last 12 months. 90 of these were resolved within 28 days. Following a review of a complaint received from the last inspection the manager confirmed that the home ensures complaints are taken seriously and dealt with in an appropriate manner. The home has recently had a change in management which it is hoped will have a impact and reduction in the number of concerns raised. The inspector viewed and discussed copies of the Homes Policy for the Protection of Residents and staff Whistle blowing procedure. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training has been provided for staff. More courses are planned to ensure all staff receive the training required to protect residents from abuse.One referral was made within the last 12month with regard to Care Homes for Older People Page 18 of 29 Evidence: the protection of vulnerable adults. Criminal Record Bureau Checks (CRB) have been obtained for all staff. The Manager is aware of her obligations with regard to ensuring the safety of Residents and protecting them from abuse. 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 benefit from living in a home that provides for a homely environment which provides safe access to comfortable indoor and outdoor communal areas. The standards of internal and external decoration were found to be of a good quality overall with some areas needing a degree of refurbishment. Residents health is protected by the homes infection control procedures. Evidence: The management and staff encourage residents to see the home as their own home. Personal items were found in many of the residents rooms to make them feel more at home. It provides a very well maintained, safe, comfortable home. As well as a good selection of general aids such as hoists and variable height beds, the home also ensures that equipment is individualised for each residents and all staff members are trained in the safe use of aids and equipment. All residents are assessed for their need to have equipment or aids before they move into the home and these are provided to them on admission. The home uses slings for the hoists in different sizes. Each resident does not have his or her own sling. For reason of infection control and the risk of cross contamination the Care Homes for Older People Page 20 of 29 Evidence: manager was requested to consult with current guidance and the Infection Control Nurse to ensure they are the home is following best practice. There is a selection of communal areas, according to the numbers of residents, this means that residents have a choice of place to sit quietly, meet with family and friends or be actively engaged with other residents. The home was found to be is well lit, clean and tidy and smell fresh at the time of inspection. The management has a proactive infection control policy. Staff wear protective clothing (gloves and aprons) when providing personal care or handling soiled linen. There are separate staff hand washing facilities in the staff room and the service kitchen. Laundry facilities are comprehensive and meet the needs of residents and current guidence. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents can feel generally confident that their care, social and emotional needs are promoted by the employment of care staff in sufficient numbers to meet their needs. However management levels at the weekend was were in need of review and shortfalls in training were noted. Residents are not fully supported by trained staff which could put them at risk. Residents are protected by the recruitment procedures within the home. Evidence: The ratios of care staff to residents are determined according to the assessed needs of residents. Following discussions with the manager, a review of the rota and observations made during the inspection. The Commission is of the opinion that sufficient care staff were on duty to support residents with their needs. However the manager was requested to review staffing to ensure sufficient management cover is available at weekends. Due to the size of the home and some of the residents complex needs it was recommended by the Commission that the home considers having management cover available seven days a week to ensure that staff receive support and direction. The manager in response to our concerns confirmed that it had already been identified that additional cover was required at the weekends and that she is Care Homes for Older People Page 22 of 29 Evidence: taking steps to the review management levels and provide extra cover. The home has recognised that it has in the past used a higher than average number of agency staff. This is being addressed and the manager showed evidence and stated that new staff are currently being recruited. Residents spoken with were happy and content with the level of support provided. Relatives who had completed comment cards confirmed this in that they felt that their relatives were adequately supported with their needs. The home employs a number of ancillary staff who work as cleaners, laundry, gardener, maintenance staff. Thus allowing care staff the time to meet the needs of residents. The staff training records indicated undertaken training. Individual and group staff training needs had been identified. From documentary evidence seen the standard of staff training was adequate overall with the majority of staff completing basic courses, but however shortfall were noted with regard to basic courses. Namely first aid, food hygiene and infection control. No evidence was additionally available that staff have received training in Dementia care. Evidence confirmed that the home meets with the required standards with regard to achieving an NVQ National Vocational Qualification Level 2 or above care qualification. The manager was able to confirm that the home has a development programme for all new staff, which meets Sector Skills Councils workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of residents, and that all members of staff receive induction training to specification. The home showed that it undertakes a recruitment practice including submission of an application form detailing all previous work history, requests proof of identity and copies of qualification certificates, seeks two written references, and confirms work status. The homes recruitment files observed were seen to include all the information as required under schedule 2 of the Care Home Regulations 2001. 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. Residents and or their relatives can be confident that their views and opinions effect how the home is run and that the home is managed appropriately. However management has only recently changed and challenges lay ahead to ensure that residents receive quality care. Residents can feel confident that their health and safety is protected Evidence: Shortfalls highlighted within this report evidence that the past management of the home has not provided for the best outcomes for residents. This has been recognised by the provider. The AQAA shows that the home has had three managers in 12 months, which has not been satisfactory for residents or staff, but a new manager has been appointed, who has the skills required to manage the home. The manager is currently in the process of becoming registered with the Commission. She has expressed a willinness to work with the Commission and ensure that any shortfalls Care Homes for Older People Page 24 of 29 Evidence: identified within this report are addressed. Quality assurance was discussed and the views and opinions of many of the residents relatives sought. They confirmed a great deal of satisfaction in living within the home and felt confident that their views and opinions were valued by the staff and management. The manager confirmed that the home does undertake quality assurance by means of asking residents, relatives to complete questionnaires in addition to healthcare professionals. This enables the home to ensure it is meeting the goals that are set out in the Statement of Purpose. The registered provider of the home does visit the home regularly and complete what is known as a Regulation 26 visit (Statutory documented visits by the provider to monitor standards within the home). This requires the provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. The AQAA shows the home has regular resident meetings and forums where the residents are able to express their positive and negative opinions. The AQAA further showed that families and friends are welcome at anytime, and there are relatives meetings where they can be updated on what is happening at Lord Harris Court. Quality Assurance questionnaires are circulated annually and the results analysed by an outside auditor Laing Buisson then the home formulates an action plan against this. The annual quality assurance assessment (AQAA) contains excellent information that is fully supported by appropriate evidence. It includes a high level of understanding about the importance of equality and diversity and a wide range of evidence showing how they have listened to people that use the service. The service demonstrates a high level of self awareness and recognises the areas that it still needs to improve. It has clearly detailed the innovative ways in which it plans to do this. The service fully recognises the importance of the AQAA and has used the content to inform its own quality assurance. The data section of the AQAA is accurately and fully completed and provides supporting evidence to the self-assessment section. The Commission viewed records relating to Health and Safety Procedures, maintenance and servicing, and risk assessments. The Commission viewed the Fire Log book, which was up-to-date. The Commission was able to evidence that checks and servicing of fire safety equipment and emergency lighting had been undertaken at the required Care Homes for Older People Page 25 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 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 Care plans must be regularly 01/06/2009 reviewed monthly to ensure that they reflect any change in needs. To ensure the health and welefare of the resident is supported. 2 30 18 It is required that that there is a staff training and development programme which meets Skills for Care workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. To ensure staff have the skills to meet the needs of residents. 01/08/2009 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. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 27 of 29 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. Care Homes for Older People Page 29 of 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!