Inspection on 26/01/09 for New Copford Place

This inspection was carried out on 26th January 2009.

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

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

Other inspections for this house

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

Inspecting for better lives Key inspection report Care homes for older people Name: Address: New Copford Place New Copford Place London Rd Copford Colchester Essex CO6 1YR     The quality rating for this care home is:   three star excellent 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: Diana Green     Date: 2 6 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: New Copford Place London Rd New Copford Place Copford Colchester Essex CO6 1YR 01206210397 01206213877 newcopfordplace@fote.org.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Friends of the Elderly Name of registered manager (if applicable) Louise Baxter Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 27 The registered person may provide the following categories of service only: Care Home only - Code PC 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 - Code OP Date of last inspection Brief description of the care home New Copford Place is a purpose built property accommodating twenty-seven service users in ground floor single bedrooms, twelve of which have a wash hand basin and toilet. The remaining fifteen bedrooms have wash hand basins only. The home is divided into three bays and on each bay there are assisted bathing and shower facilities. Care Homes for Older People Page 4 of 29 care home 27 Over 65 27 0 Brief description of the care home In addition there are three lounges and one large dining room, all located around a central courtyard garden. Catering and laundry services are on site. New Copford Place is set in a countryside setting, with each service user having access to the surrounding open plan lawn and wooded garden from their room. The property is set back down a lane entrance off the main road through the village of Copford. Local shops, post office, pubs and churches are to be found in the village. The home has its own minibus which is shared with the adjacent sheltered housing accommodation. The current fees are £575.00 -£608.00 per week. This does not include costs for hairdressing, chiropody, dentist, optician, personal toiletries, newspapers and magazines and clothing which are charged at cost . This information was provided on 27th January 2009. 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: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced inspection took place on 26th January 2009. All of the key inspection National Minimum Standards for Older People, and the intended outcomes, were assessed in relation to this service during the inspection. The report has been written using accumulated evidence gathered prior to and during the site visit, including the homes (AQAA) Annual Quality Assurance Self Assessment. The Annual Quality Assurance Assessment (AQAA), a self assessment that focuses on how well outcomes are being met for people using the service, was completed by the home and returned to us prior to the visit to the home. Information received in the self assessment provided us with some detail to assist us in understanding how the registered persons understand the services strengths and weaknesses and how they Care Homes for Older People Page 6 of 29 will address these. The inspection process included reviewing documents required under the Care Home Regulations. A number of records were looked at in relation to residents, staff recruitment, staff training, staff rotas and policies and procedures. Time was spent talking to residents, their relatives, staff, the deputy manager and to the registered manager who was on a study day and attended during her lunch period. This is the first inspection undertaken by CSCI since registration of the service under the new provider Friends of the Elderly. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 29 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. People planning to live at New Copford Place can expect to be fully informed about the service provided at the home prior to their admission. Evidence: Residents and their relatives spoken with during the site visit to the home said they were provided with sufficient information about the home to enable them to make a decision about moving in. The statement of purpose and service user guide were observed on display in the entrance hall of the home for visitors information. Assessments were present on the three files viewed and included assessments for personal and health care needs, mobility, dietary needs, likes and dislikes including activities and how they liked to spend their day. The statement of purpose stated that when a new resident joins us we prepare an Care Homes for Older People Page 11 of 29 Evidence: individual plan of care with them and their relatives.....the plan covers all aspects of how we can make their stay enjoyable and comfortable. A relative told us that there was a three month settling in period to ensure that residents were happy at the home and their needs were being met and said I feel like I am coming home. They make me feel at home. The home does not provide intermediate care. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at New Copford Place can expect to have their needs met through care planning that is closely monitored, regularly reviewed and provided by skilled, experienced and well supervised care staff. Evidence: Three residents files were viewed. Each record contained a pre-admission assessment of need. Assessments included nutritional assessment, preferences, pain assessment, skin assessment, dependencies and mouth care assessment. Risk assessments were recorded for individual risks, for example for risk of falls, environment, use of bath, use of hoist. Monthly reviews were evident in all three files viewed, showing that residents changing needs were monitored to ensure appropriate care was being given to meet their daily needs. Daily records were recorded detailing the care that had been given and showed that there was good monitoring of care needs with appropriate action taken as needed. For example one residents changing needs could no longer be supported at the home. Discussions had been held with the family and social worker to so that an appropriate placement could be found. Another resident usually had a bath Care Homes for Older People Page 13 of 29 Evidence: supported by one carer but due to care being given by a district nurse this was not recommended. The records confirmed on that day only foot care had been provided. Another resident had difficulties in swallowing. The manager ensured staff had appropriate support and were trained to enable them to take appropriate action in the event of an incident occurring. This included providing a guidance leaflet on choking and first aid training which included management of choking. There was evidence in the records that residents were enabled access to GPs, district nurses, chiropodists, opticians and dentists and attended outpatient appointments as needed. A GP told us the senior staff are very good and the medical care is excellent. When asked what does the service do well, a healthcare professional told us they communicate with professionals and the family very well. Staff were observed to treat residents with respect by addressing them politely with their preferred name as indicated in their care plan. Personal care was provided in residents rooms and bathrooms in private. One relative told us my x is treated with respect, kindness and great care. x dignity is considered and the staff are wonderful. We were informed that staff were encouraged to undertake training in etiquette and the interactions observed between residents and staff were testament to the outcome achieved from the training. The home had a medication policy and procedures that provided comprehensive guidance for staff and included procedures for as required medication. Additional guidance was available to ensure that staff were able to check information on medicines including potential side effects. Medication was supplied in monitored dosage systems and individual containers from the supplying pharmacist. Procedures were in place to ensure the safe receipt and disposal of medication that were well adhered to. Medication was stored safely in a locked medication trolley that was secured to the wall and in a separate locked clinical room. The home had a controlled drugs (CD) storage cupboard and a drug refrigerator that was well maintained, regularly defrosted with regular monitoring of fridge temperatures undertaken. The room temperatures should also be regularly monitored to ensure they remain within safe recommended levels (below 25 degrees Centigrade). Medication was administered by designated care staff with appropriate training. A list of staff signatures and initials was maintained that enabled appropriate follow up in the event of an adverse incident. We were informed that all staff had undertaken a safe handling of medication course and had attended a recent updated course. Annual assessment of competencies was undertaken and this was confirmed from three staff files viewed. Care Homes for Older People Page 14 of 29 Evidence: The medication supplies and records for three residents were inspected. All medication was available as prescribed. The records were accurate and recorded in full. Weekly audits were undertaken and confirmed by staff signature. We were informed that the manager regularly checks to ensure that staff practice is safe and this was also confirmed from the staff files viewed. Two residents files included a pain assessment that enabled staff to monitor any patterns and to ensure that pain relief was effective. This was reviewed weekly and showed that staff ensured that residents pain was relieved as far as possible. This was good to see. The CD register and supplies were inspected and found to be accurate and completed in full with evidence that two staff members signed to confirm accuracy as is required. We were informed that an End of Life Care initiative had recently been implemented in the care home supported by the Macmillan Nurse Team and district nurses. The expectation was that this would encourage residents to become more involved in planning their care during the final stages of their lives and enable them to influence how they would like their care to be given. The manager demonstrated good knowledge and was clearly motivated to improve standards and staff skills through training and development. A palliative care file was viewed that contained various leaflets, magazines and publications from the National Council for Palliative Care (an umbrella organisation that promotes palliative care in health and social care settings). The file provides an excellent resource for care staff at the home by providing expert knowledge and guidance on end of life care. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at New Copford Place can expect to be encouraged to maintain contact with their family and friends and to have a lifestyle that satisfies their cultural expectations and needs. Evidence: The home had several small lounges and seating areas that enabled residents to watch television, engage in conversation with others, take part in activities, or sit quietly and read. The activities coordinator explained the range of activities on offer during the site visit. On admission she meets with residents to discuss their likes and dislikes and tries to accommodate their choices through a planned programme. The home had a WII game, a large TV screen for DVDs. Various activities were provided including board games, quizzes, bingo, scrabble, craft, making cakes and growing vegetables. We were informed that last year residents had been encouraged to take part in a competition for growing sunflowers and they were already discussing which vegetables to grow this year. Entertainment was provided with a singer and story teller, musical quizzes and pantomimes were also organised during the Christmas period. During the site visit eight residents were seen taking part in a quiz in one of the lounges while others chose to stay in their rooms or read. The home had access to a minibus on Care Homes for Older People Page 16 of 29 Evidence: Mondays and Wednesdays and outings were arranged to Clacton, Castle Park Colchester, shopping and to Sainsburys. A seated exercise session had recently commenced and a visiting clothes shop was also provided. Residents spoken with said they looked forward to the activities and opportunities to go on outings. One resident told us they are keen for you to participate in the activities and the staff are all very helpful and prepared to chat to you. We were informed that nine residents supported by nine staff had gone on holiday to Yarmouth last year staying in individual wheelchair accessible caravans with a mix of staff supporting them based on their needs. The AQAA informed us that the home had a beach hut that they planned to make more use of during the coming summer. The homes statement of purpose included the homes policy on visiting. A resident told us my friends come in every day and a relative said I come in every morning and go into the office. They make me feel at home. A relative who completed a survey told us we are all welcomed and treated wonderfully which enables x to enjoy x visitors. Residents were observed to have a choice about their daily lives, for example what time they got up, where they spent their time and taking part in activities or not. Many of the rooms seen were well personalised showing that residents could bring in personal items to make them feel at home. The statement of purpose stated we never forget this is the residents home and this was evident by the respect shown by all staff during the site visit. The dining room is open plan leading from the entrance hall of the home. The tables were laid with clean tablecloths, cutlery, condiments, water jugs and and fresh flowers creating a pleasant ambiance for residents to enjoy their meal. Menus were provided on each table, and vegetables were provided in serving dishes to enable residents to serve themselves as they wished. The lunch-time meal was observed and comprised a choice of toad in the hole or chili con carni with rice, potatoes and fresh vegetables or salad. Other choices were also provided for individual residents as they had chosen. Staff were observed to assist residents with eating in a sensitive and discreet manner with no pressure on time. One member of staff told us giving them time to enjoy their meal and making it as gracious as possible is such a small thing - but it means a great deal to them. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at New Copford Place can expect to have their complaints listened to and acted upon and to be protected from abuse by robust policies, procedures, staff training and practices. Evidence: The home had a complaints procedure that was included in the statement of purpose and displayed in the entrance of the home. The procedure included the timescales within which complainants can expect for a response and advised them of their right to refer to senior management within the organisation and included the address of the local office of CSCI. Residents spoken with said they would feel at ease to talk to any member of staff if they had a concern, One resident told us staff are responsive. A record of complaints was held in the front hall. This was in sufficient detail but was also respectful of privacy. The home had an abuse policy and procedures for staff guidance and a whistle blowing policy. The process was discussed with the deputy manager who explained that safeguarding was included in the mandatory training for all staff. Safeguarding was also regularly discussed at staff meetings and confirmed from minutes seen dated 7/08/08. Role play was also used to demonstrate the reporting procedure. Safeguarding was planned to be offered to staff during 2009. Training records dated 28/11/08 confirmed that eight staff had attended safeguarding and protection of Care Homes for Older People Page 18 of 29 Evidence: vulnerable adults training including the kitchen manager, care staff and the deputy manager. 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. People living at New Copford Place can expect to live in a homely environment that is well decorated, well maintained, clean and odour free. Evidence: A tour of the premises was undertaken during the site visit that included communal areas, several bathrooms, a number of residents rooms, the sluice, laundry, kitchen and clinical room. The home was arranged in three bays, all overlooking the quadrangle garden. Each bay had nine individual residents rooms, some of which overlooked the surrounding gardens. The home was well decorated and well maintained. Residents rooms had access via a patio window to the gardens that were laid mainly to lawn with planting of shrubs and trees. We were informed that the gardens were used for summer fetes to which residents families and friends were invited. Records and staff practices seen confirmed that the home complied with the requirements of the local fire and environmental health department. Residents accommodation was provided on one floor and no passenger lift was therefore provided. Some staff facilities were provided on the first floor and accessed via stairs. There were grab rails and aids in bathrooms and toilets to meet the needs of residents. Call systems were provided in all individual rooms and communal rooms. A range of specialist pressure relief mattresses and cushions were provided by the Care Homes for Older People Page 20 of 29 Evidence: district nursing service together with other equipment (hoists, perching stools and walking frames) to meet residents individual needs. The records seen confirmed that all equipment owned by the home was serviced as per manufacturers recommendations. The home had infection control policy and procedures for staff guidance. We were informed that infection control training was considered mandatory for all staff and the records viewed confirmed that all staff had attended training. Staff hand washing practices were observed to follow safe practice. The cleaning of bedpans and commode pans were discussed with care staff and were found to meet with guidance provided from the Health Protection Agency. However additional racking needs to be provided to ensure equipment can be effectively dried. The laundry room was sufficient for the size of the premises and was equipped with two washing machines, one which had a sluice facility (i.e. ability to wash at minimum of 65 degrees Centigrade for not less 10 minutes) to thoroughly clean linen and prevent the risk of infection and two driers that were all confirmed to be in working order. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at New Copford Place can expect to be cared for by a skilled and motivated staff team with staffing levels that are appropriate to meet their needs. Evidence: There were twenty-seven residents at the home and staffing levels were confirmed at one senior care staff and 3 care staff in addition to the deputy manager. The registered manager for the home was on study leave but attended for a short period during the site visit when she was able to provide additional information about the service. From discussion with residents and observation staffing levels were found to be sufficient to meet the needs of residents. One resident told us all the staff are very helpful and usually have time to have a chat and answer any problems you may have and another told us all the staff are spendid. Ancillary staff were confirmed on duty to be the administrator, the cook and one assistant cook, the activities coordinator, one domestic assistant, one laundry assistant, maintenance person and two gardeners. The AQAA informed us that the home constantly strives to achieve a minimum of 50 of care staff with an NVQ level 2 qualification. During the site visit the deputy manager was able to confirm that 60 of staff had a qualification or were undergoing training to achieve a qualification at NVQ level 2, 3 or 4. Care Homes for Older People Page 22 of 29 Evidence: The recruitment records were viewed for three members of staff who had been appointed since the previous key inspection. All included evidence that the required checks (two satisfactory references, CRB/POVA checks) full employment history and evidence of identification and photographs were obtained prior to appointment. We were informed that all references were checked by telephone to ensure they were valid. One staff member had recently remarried and the manager was awaiting evidence of the name change for the records. The files also contained evidence that the homes induction (based on the Common Induction Standards) had been undertaken and competencies assessed. The home had an established comprehensive training programme. We were informed that the new organisation was very supportive of staff attending training ensuring that they were regularly updated and competent in their practice. The mandatory staff training programme included moving and handling, fire safety, health and safety, food hygiene, infection control, safeguarding adults from abuse and interpersonal skills (confirmed from the records). Staff were also encouraged to attend training on grief and bereavement, and etiquette skills. The training records for the recently recruited staff included evidence they had undertaken health and safety training, training in moving and handling, fire safety, Control of Substances Hazardous to Health (COSHH), Reporting of Injuries, Diseases and Dangerous Occurrences (RIDDOR) and had been provided with booklets on dementia care. A copy of the Friends of the Elderly Strategy News was provided for August 2008. This included the strategic aims of the organisation and how this is being achieved throughout the whole of the organisation. News of staff developments, opportunities and achievements were detailed in the newsletter, providing staff with guidance as part of a team and stimulating personal and team development. Training was also discussed with the manager (who had taken a lunch break from attendance at a Safeguarding Adults training day) and the deputy manager. We were informed that staff were currently undertaking safe handling of medicines (confirmed from the records), senior staff had attended training on the Mental Capacity Act and the manager was booked to attend Deprivation of Liberty (DOLS) training. 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. People living at New Copford Place can expect to live in a well managed home that is run in their best interests and through robust policies, procedures and practices that are well monitored, ensures they and staff are safeguarded. Evidence: The manager is an experienced and competent manager who has managed the home for a number of years and has completed the Registered Manager Award. The manager is supported by a deputy manager. There was evidence that both had undertaken regular updated training. One resident told us the manager is very good, very approachable and a relative told us my x has been at New Copford Place for 10 years and seen great changes. Louise is the best manager the care home has had in that time. We as a family trust her completely and always feel we can talk to her if we have any concerns. The homes quality assurance was discussed with the deputy manager. The home had Care Homes for Older People Page 24 of 29 Evidence: a quality assurance programme that included service user and relative questionnaires. Regular residents meetings were held and a notice was seen displayed when the area manager next planned to visit the home at which time she would be available to meet with residents and relatives. An action plan had been developed from the outcome of the comments received which formed an annual plan for the home. The Friends of the Elderly had not yet implemented a quality review since acquiring the service. However monthly audits continued to be undertaken by the manager including care plans, service areas and health and safety (also confirmed from the records viewed) and there was evidence that action was taken to address issues identified. We were informed that the home were working to achieve Investors in People Award. The systems for handling residents monies were discussed with the deputy manager who informed us that it was the residents choice whether they wished to use the homes finance system. The records for four residents were inspected. Transactions were recorded with receipts of expenditure held and signed by staff. All cash held was confirmed to be correct. Internal audits were undertaken weekly and senior management also undertook audits that were reported under Regulation 26. Neither the manager nor the deputy manager were appointee for any resident. Personal items (i.e. cheque books, small items of jewelry were kept in the homes safe and receipts were provided to residents. Any return items were also confirmed by a signed receipt by the resident/relative. The arrangements for staff supervision were discussed with the deputy manager. Each member of staff has six supervision sessions which includes an annual appraisal during the year. The organisation had a policy for annual performance reviews which were undertaken by the manager and deputy manager and countersigned by the Director of Care. The manager supervises the deputy manager and senior care staff. Senior care staff have responsibility to supervise care staff and are provided with guidance on the areas to be covered. A tracker system is in place to ensure that meetings take place as planned. one recently employed member of staff told us my manager has met with me on several occasions during my induction to ensure that I am happy and understand everything. Records held on behalf of residents were were kept up to date and were stored safely in secure facilities. Records viewed at this inspection included the statement of purpose, service users guide, assessments/care plans, medication records, a sample of policies and procedures, complaints, staff meetings, residents meetings, staff recruitment and training records, maintenance records and fire safety records. The home had health and safety policies and procedures that were regularly reviewed. The records confirmed that staff had attended relevant health and safety training. A Care Homes for Older People Page 25 of 29 Evidence: sample of records viewed showed that were were systems in place to ensure the servicing of equipment and utilities and there was evidence of weekly and monthly internal checks being carried out (e.g. checks on fire equipment, fire alarms and emergency lighting). All accidents, injuries and incidents were well recorded and confirmed that appropriate action had been taken. One radiator situated in the entrance hall of the home had not been covered and no risk assessment had been recorded. This was discussed with the manager following the site visit who confirmed that action would be taken to have it covered. Care Homes for Older People Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 9 The medication room storage temperature should be monitored to ensure it remains within safe limits (below 25 degrees Centigrade). This will ensure medication has not deteriorated and therefore safe to administer. Action should be taken to ensure that the radiator located in the entrance of the home is guarded or has a low surface temperature. 2 38 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. 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