Inspection on 15/01/09 for Mont Calm Folkestone

This inspection was carried out on 15th 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

Mont Calm Folkestone 12/11/07

Mont Calm Folkestone 28/07/06

Mont Calm Folkestone 06/09/05

Mont Calm Folkestone 28/04/05

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

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Mont Calm Folkestone 24/26 Earls Avenue Folkestone Kent CT20 2HE     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: 1 5 0 1 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: Mont Calm Folkestone 24/26 Earls Avenue Folkestone Kent CT20 2HE 01303251600 01303251000 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Mont Calm Folkestone care home 28 Number of places (if applicable): Under 65 Over 65 0 dementia Additional conditions: 28 The maximum number of service users who can be accommodated is: 28 The registered person may provide the following category/ies of service only: Care home only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - DE Date of last inspection Brief description of the care home Mont Calm is a care home providing care for up to 28 people with a diagnosis of dementia. The home is situated in an avenue, a short walk from the popular Leas area of Folkestone. There is a mainline railway station and local bus routes nearby. The current fees for the service at the time of the visit range from GBP387 to GBP540.00 per week. Information on the Homes services and the CSCI reports for prospective service users will be detailed in the Statement of Purpose and Service User Guide. Care Homes for Older People Page 4 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 8:10AM on 15th January 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 the previous report and discussion and correspondence Care Homes for Older People Page 5 of 29 with the registered 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 had the benefit of having the assistance of an expert by experience. The Commission is committed to involving experts by experience in both service and regulatory inspections. The Commission uses the term experts by experience to describe people who use services of have experiences of services. The report provided by the expert by experience has contributed towards helping the Commission making judgements about the home. 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 :The homes care plans do not currently use a socially led model. From the care plans viewed they were of a medical / clinical approach. The plan of care needs to better evidence social and personal goals including hopes, goals and aspirations where possible. We visited the home at 8:10AM and found all of the residents up eating their breakfast in the dining room. Whilst it is accepted that many residents may choose to rise early it Care Homes for Older People Page 7 of 29 was felt by the Commission that having what appeared all of the residents up at 8:10AM was a concern. The manager was requested to review the staffing arrangement to ensure that staffing convenience is not dictating routines. Social care planning was not fully evidenced within the care planning process. All core courses have not been undertaken for all staff to maintain current qualifications and for protection of residents. Staff additionally have not achieved NVQ qualifications in Care to level 2 or above to meet with the required standards of 50 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 feel confident that their needs will be properly assessed prior to moving to the home. However documentation needs to be improved. Intermediate care is not provided. Evidence: The standard relating to the assessment of residents prior to them moving into the home was met at the previous inspection. However whilst in discussions with the manager showed that residents have an assessment, the assessment needs to be fully evidenced and contain the elements as required of the standards within the care planning system. The manager stated that she would better evidence this in future. No statutory requirment has been made at this time as the Commission is confident that this will be addressed. Care Homes for Older People Page 10 of 29 Evidence: The AQAA and attitudes of staff recognises cultural needs and the importance of promoting equality and diversity rather than just meeting needs in a reactive manner. The Commission however recommended that the home reviews it equalities and diversity policy and considers carrying out an equalities impact assessment. This is requested due to the lack of evidence of social care planning (later detailed in report), to ensure that all of the information and policies relating to residents are inclusive to all members of the community and comply with all current legislation and good practice. Additionally it was recommended that Equality and Diversity training for all staff including management is considered and actioned. The home does not provide intermediate care. 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 benefit from having individual plans that identify their physical and medical needs and provide the support they need, but not enough detail was given to social and personal goals. Residents can feel confident that they are fully supported with their health care needs. Residents can feel overall confident that the homes policy and procedures with regard to the administration and dispensing of medication is sound. Residents dignity is not always upheld all the time due to staffing conveniencedictating routines. Evidence: We discussed with the manager the care records relating to several residents at Mont Calm. In the care plans viewed there were guidelines in respect to support needed. The home undertakes regular reviews. Formal reviews involving significant Care Homes for Older People Page 12 of 29 Evidence: professionals where possible are also undertaken. The homes care plans do not currently use a socially led model. From the care plans viewed they were of a medical / clinical approach. The plan of care needs to better evidence social and personal goals including hopes, goals and aspirations where possible, to better evidence the current support given to residents at the home. We viewed a sample of care records and specific health care records relating to several residents. Records viewed confirmed residents had access to a range of health care input as and when required but not as part of regular health checks. This included access to their chosen G.P (where possible), Dentist, Optician and Chiropodist in addition to identified specialist health care input. The Home facilitates residents keeping hospital appointments and seeing their own GP. It is evident through talking to members of staff at the home that the wellbeing of the residents is of a high priority and that staff are pro-active in maintaining and supporting residents with their needs in order to maintain their quality of life. Risk assessments were reviewed within the home and discussed with the manager. Assessments seen detailed how to support residents to minimise risks for personal safety and had been updated and reviewed. We viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of Medication within the home. The manager confirmed that all staff who dispense medication have received the appropriate training from South Kent College. Storage was available for controlled drugs. The manager stated that it was in line with current guidance. This now satisfies the outstanding requirement from the previous inspection. A second drugs trolley is now in place. This was a recommendation from the previous report. The inspection of the homes system for storage and the administration of medication brought to light only one concern. It was apparent following discussions with the manager that audits are not regularly carried out to confirm that staff are following medication policies and procedures and that medication is recorded properly. The manager stated that this shortfall would be addressed as a priority. No statutory requirements in respect of medication have been made at this time. We visited the home at 8:10AM and found all of the residents up eating their breakfast in the dining room. Whilst it is accepted that many residents may choose to rise early it was felt by the Commission that having what appeared all of the residents up at 8:10AM was a concern. The manager was requested to review the staffing arrangement to ensure that staffing convenience is not dictating routines. Care plans need to confirm that rising early is a choice or a past behaviour which can be confirmed if possible by a relative. Care Homes for Older People Page 13 of 29 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents engage in a good level of activities which are appropriate to their needs and capabilities. Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The residents benefit from the appetising meals and balanced diet offered at the home. Evidence: Discussion with staff, residents where possible and other evidence confirmed that the level of activities were of a good quality and that they enjoyed a good level of stimulation through leisure and recreational activities. Residents were observed participating and interacting with staff. Residents have been enabled to and encouraged to participate in activities which they had an interest in. Care Homes for Older People Page 15 of 29 Evidence: The expert by experience stated that the lounge was brightly decorated with matching furniture, photographic collages of events e.g. parties, Halloween, Christmas and Easter events, showing participation of staff and residents. She spoke to the Under Manager and staff about activities and was given to understand and saw photographic evidence of activities which had taken place. Whilst in the lounge at lunchtime a resident suddenly burst into song and others joined in including the staff. This was a happy and spontaneous occasion and was enjoyed by the other residents. Social care planning was not fully evidenced within the care planning process. This was identified elsewhere within the report. The manager stated that she will further identify and evidence social aspects within the residents care plans. It was confirmed that residents are enabled to maintain contact with relatives and friends where they wished to do so. From observation, records viewed it was evident that residents were offered a choice of menus that meet their dietary needs and individual preferences where possible. The cook kept a card system for residents with their likes and dislikes. The expert by experience stated that before entering the kitchen area a plastic apron had to be used and clinical washing facility adhered to. She spoke at some length to the cook and saw a two week prepared menu chart, showing a variety of dishes for that time. She was told that cakes are often made for afternoon tea and alternatives were offered for breakfasts. That day, as well as cereal, toast, cooked breakfasts, crumpets were on offer. Cupboards were adequately stocked with tins of fruit, jams, beans etc but limited evidence of fresh ingredients was available. The cook stated that these were on order and due for delivery the next day. One resident did like curry and often had this. Residents did appear to enjoy the meals and the expert by experience saw no waste. On entering the lounge staff had the facility for hand cleaning. Tables were set out for three or four residents who had limited communication between them. A small alcove was also set aside for those residents who needed support with eating from staff. The atmosphere was homely and welcoming. Care Homes for Older People Page 16 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 feel confident that their concerns and complaints are taken seriously. Residents are are protected from the risks of abuse. Evidence: A copy the complaints procedures was reviewed. The procedure included details of how to complain, timescales for response and information for referring a complaint to the service provider. It was recommended by the Commission that the complaints procedure also be made available in a larger print. Residents within the service have an understanding of how to make a complaint as their capacity and understanding allows. No complaints have been received from information contained within the AQAA. One referral has been made to Social Services under the safeguarding adult procedures. Any concerns with regard to safeguarding adults were seen to be dealt with appropriately and did not raise any concerns with regard to actions taken by the home. Systems are in place to ensure that complaints / concerns are dealt with to achieve the best possible outcome for the complainant. The homes Policy for the Protection of Residents and staff Whistle blowing procedure was discussed. 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, evidence of this was seen within the staff files and Care Homes for Older People Page 17 of 29 Evidence: training record. Further evidence and the AQAA showed the Complaints procedure is displayed within the home. Residents and families are give a copy of the complaints procedure on admission and they are also verbally informed where possible about the procedure by the manager. All staff trained in NVQ 2 have covered a module of adult abuse staff have also attended a study day on protecting vulnerable adults. Robust policies and procedures are in place as well as having such documentation in place as the Kent and Medway Adult Protection procedures. Communication is effective and residents and families feel comfortable to raise and concerns or worries. The manager stated that Criminal Record Bureau Checks (CRB) had been obtained for all staff . 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 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 good well maintained environment which provides a homely warm atmosphere. Residents are not fully protected by the homes infection control procedures and policies Evidence: The environment was rated as poor at the previous inspection and did not provide a well maintained home for residents. It was evident at that time the home did not have a rolling maintenance programme. During this inspection however it was clearly evidence that the environment has improved. Many parts of the home have been re-decorated and new carpets laid. Bathrooms and toilets have been upgraded along with hallways and stair wells. Areas identified in the homes improvement plan as outstanding have been addressed. Plans are in place to remove some of the internal walls downstairs to increase the communal space and provide unsupervised access in good weather to two raised patio areas. It is apparent from discussions with the manager that this is an improving situation. The maintenance manager took great pride in showing the building and the plans to Care Homes for Older People Page 19 of 29 Evidence: improve it. It is clear that the collective needs are generally being met in a comfortable environment. However two issues are required to be addressed. The first relates to the quality of the bedroom furniture which was found to be variable and the condition of some of the mattresses in some of the rooms. The manager agreed that attention in this area was needed. Subsequently to the inspection she confirmed in a telephone call that the owner had agreed to a replacement programme. This is now being implemented and new furniture and mattresses being ordered. Secondly it was highlighted at the last inspection that access to the garden should be facilitated and this was seen as a shortfall. Upon consultation with the manager and the maintenance manager and inspection, the Commission has reviewed its judgement and agreed that a double ramp at the back of the home is not practical. The rationale for this change is that it is recognised that due to the size of the garden the installation of a double ramp would leave no garden left for the residents to enjoy. The home was not purpose built and the basic geography of the building can not be changed. The home does have a ramp at the front and access to the park at the rear of the home can be obtained through a side alleyway with staff support. However it was stated by the Commission that access through the two double doors in the lounge, once walls are knocked down to the raised patios should be improved and made safe. An environmental and personal risk assessment should be undertaken for each resident and adjustments made where possible to facilitate such access. No requirment has been made at this time in aticipation of a positive outcome once further improvements are made. This will be further reported on at the next inspection. It is kept hygienically clean to a high standard. Bedrooms have been personalised to suit individual tastes. Residents are encouraged to bring personal belongings and furnishing to aid transition and ensure that they will be comfortable in the care home with their own personal belongings. The communal bathrooms have a bath hoist and toilets on the ground floor. The lounge and dining area furnished with comfortable chairs. The kitchen appeared clean and well maintained. Fire risks assessments have been carried out and all fire systems are checked regularly by contractors. Staff carry out weekly fire alarm testing and monthly emergency light checks. Only one staff member out of twenty nine however has recieved infection control training. This is addressed later in the report. All bedrooms promote high levels of privacy but do not presently have locks. All residents should they so wish have a key to their own room unless a person centred risk assessment indicates otherwise. The manager stated that she would canvass residents wishes, provide locks, risk assess and document. Care Homes for Older People Page 20 of 29 Evidence: The home is very well lit, tidy and smells fresh. The premises are kept clean, hygienic throughout and systems are in place to control the spread of infection. The manager stated laundry facilities currently meet the needs of the residents living within the home. The laundry area consists of a industrial washing machine and tumble dryer. Contracted hygiene specialists remove yellow bags and sharp boxes from the premises. Policies, procedures and risk assessments are in place. 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 care, social and emotional needs are promoted by the employment of caring staff in such numbers to support their needs who put the interests of the residents first. Residents can not feel confident that staff are trained to the required standard. Residents can feel confident that they are supported by staff who have been employed by the home using good recruitment procedures. Evidence: From discussions with the manager, observations and reviewing the staff rotas sufficient staff were on duty at the time of inspection to meet the residents needs. Staff are receptive to residents needs and work together as a team. The expert by experience spoke to several staff and observed their interaction with residents. The atmosphere was harmonious; residents were treated kindly with care and dignity. The expert by experience further stated that there appeared to be strong team spirit and communication. She spoke to two cleaners who had been with the home for some time and had transferred from being care assistants to cleaners because of unsocial hours and she spoke to one care assistant who had transferred from cleaning to caring. All were happy with their roles and enjoyed their work. Evidence of this was gathered Care Homes for Older People Page 22 of 29 Evidence: from the AQAA and practise observed by the expert by experience. The manager stated staffing levels are always under review to ensure the needs of the residents are met. Risk assessments have been prepared both for the residents as individuals and the environment. The staff training records indicated undertaken training in all the key areas. The large majority of staff have now received training in the protection of vulnerable adults and dementia. This was a outstanding requirement from the previous inspection. However all core courses have not been undertaken for all staff to maintain current qualifications and for protection of residents. Staff have not achieved NVQ (National Vocational Qualification) qualifications in Care to level 2 or above to meet with the required standards. From the training matrix provided only five out of the nineteen care staff have a qualification, not meeting the target of 50 , only one staff member out of twenty nine has recieved infection control training and seven out of twenty nine fire training. The manager confirmed that the home has a development programme for all new staff. However it does not meet with the 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 manager is aware of the shortfall in training and induction and is taking steps to address it. Evidence was seen of fire training, which is now booked. The inspection of the recruitment files at the previous inspection evidenced that the required checks had been carried out and that the standard was met. No intelligence would suggest that standards do not continue to be maintained. This standard was not inspected on this occasion.The manager stated all required information was contained within the files and checks of identity have been carried out. Staff have CRB (Criminal Record Bureau) checks. 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 needs are currently being met and they can be confident overall that the home is managed appropriately to meet their needs. However it is recommended that the quality assurance process be more detailed and shortfalls identified within this report are addressed. Residents can feel generally confident that their health and safety safety is protected. Further training is however needed for staff. Evidence: The manager is actively involved in the day-to-day management of the home and works with staff and residents. She has many years of experience caring for others. She is currently not registered with the Commission. However she is currently applying and is awaiting on various pieces of documentation. Outcomes for the quality of care are good. Residents expressed a great deal of Care Homes for Older People Page 24 of 29 Evidence: satisfaction of the care provided and the staff are very supported of the manager and have a positive ethos. Evidence of this was gathered from the AQAA and talking to staff, who all felt well supported and stated that the manager was very hard working. Quotes direct from staff include Home running well and Good team working There is strong evidence that the ethos of the Home is open and transparent. The views of both residents and staff are listened to, and valued. However shortfalls have been noted within this report in respect of staff training, induction training, and evidence of assessments along with other areas to be improved. The manager has demonstrated a willingness to work with the Commission and stated that the identified shortfalls would be addressed as a priority. Quality assurance was discussed and the views and opinions of many of the residents and stakeholders sought. Feedback from the AQAA, staff and the expert by experience and others confirmed that the home tries to deliver a good service and is receptive to suggestions and comments. An appointed person of the registered provider of the home does regularly visit the home and completes what is known as a Regulation 26 visit. 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 manager confirmed that the home has a quality assurance process in place that measures the quality of care given and that the views of residents are included. Medication Audits were also not evident. The Commission recommended that the level of detail within the Reg 26s be in more detail. Evidence of health and safety safety checks were inspected. Evidence showed that required checks had been carried out and the manager stated that they were up to date. Direct evidence of this was seen in the way of records and certificates. Shortfalls were noted around heath and safety. This is reported elsewhere in the report. Evidence was available however by the way of a copy confirmation from a local College that fire training is booked. 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 10 12 The registered person shall 15/02/2009 make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of residents. The registered person needs to ensure that staffing convenience is not dictating routines for residents. 2 30 18 The registered persons shall ensure that staff receive training and induction that meet with the Skill for Care Councils current guidance, law and supports residents with their needs To ensure that residents needs are met and that they are protected as far as possible with regard to health and safety. 15/05/2009 Recommendations Care Homes for Older People Page 27 of 29 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 23 It is recommended that the home carries out an audit of the furniture within residents rooms supplied by the home to satisfy the provider that it is well maintained and of sufficient quality. It is strongly recommended that all staff receive training in the Mental Capacity Act 2005 and Deprivation of liberty safeguard regulations. 2 30 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. 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