Inspection on 18/11/08 for Northway House Residential Home Limited

This inspection was carried out on 18th November 2008.

CSCI found this care home to be providing an Good 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

Northway House Residential Home... 16/06/09

Northway House Residential Home... 19/11/07

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Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Northway House Residential Home Limited 96 - 98 Kingston Road Taunton Somerset TA2 7SN     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: kathy McCluskey     Date: 1 8 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Northway House Residential Home Limited 96 - 98 Kingston Road Taunton Somerset TA2 7SN 01823253999 01823325255 jay.n.patel@aaroncourt.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ms Paulene Rosina Coles Type of registration: Number of places registered: Northway House Residential Home Ltd care home 29 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 29. The registered person may provide the following category of service only: Care home providing personal care - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (Code OP) Date of last inspection Brief description of the care home Northway House is a large detached Victorian house, situated close to Taunton town centre. Bedrooms are provided on the ground and first floor. There are two lounges, a conservatory and a large dining room. The home has a passenger lift, call system, and adapted bathrooms. There is a well maintained garden at the rear of the home that is easily accessible. Northway House is registered with the Commission for Social Care Inspection to provide accommodation for up to 29 people over the age of 65 years who Care Homes for Older People Page 4 of 30 Over 65 29 0 Brief description of the care home require assistance with personal care. The home does not provide nursing care or care to people with dementia. The home also provides day care. The registered provider is Northway House Residential Home Ltd. The responsible individual is Mr J.Patel. The home is currently without a registered manager. Care Homes for Older People Page 5 of 30 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 homes last key inspection was conducted on 19th November 2007 where twenty statutory requirements were raised. An additional inspection was carried out on 16th June 2008 to follow up the homes progress in meeting these requirements. Eighteen of the twenty requirements were assessed and the home had taken action to address fourteen of these. This unannounced key inspection was conducted over one day (8.25hrs) by CSCI Regulation Inspector Kathy McCluskey. The acting manager and company representative were available throughout the inspection and the responsible individual arrived at the home part way through the Care Homes for Older People Page 6 of 30 inspection. At the time of this inspection, 28 people were residing at the home and we were able to speak with 18 people in depth. We were also able to meet with care staff on duty. We were given unrestricted access to all parts of the home and all records requested for this inspection were made available to us. The home submitted its Annual Quality Assurance Assessment (AQAA) to the Commission within agreed timescales. The AQAA is a self assessment which details the outcomes for people using the service. It also gives us some numerical information about the service. As part of this inspection the Commission sent comment cards to people living at the home and to staff working there. We received completed comment cards from 5 people using the service and 1 member of staff. Extracts from the AQAA and comments received have been incorporated within this report as appropriate. We would like to thank all involved for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the care home does well: What has improved since the last inspection? The home have ensured that care plans are fully reflective of individuals assessed needs. The acting manager has plans to further improve the care planning format to make it more accessible. People were very positive about the improvements made around activities. The home Care Homes for Older People Page 8 of 30 has employed an activities coordinator who has devised an activity programme which is based on the views of the people living there. This improvement has had a positive outcome for the people living at the home. The registered person has implemented a major refurbishment and redecoration programme which is on-going. People spoken with were very positive about the improvements already made. At this inspection we were able to see evidence that the home had taken action to address all of the six remaining requirements from the additional random 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 9 of 30 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 30 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 thinking about using service are provided with information which enables them to make an informed decision about moving there. The home ensures that people are appropriately assessed before a placement is offered. Evidence: The home has produced a Statement of Purpose and Service User Guide which provides people who are thinking about using the service, with information about the home and services offered. Each person who moves to the home is provided with a contract which details the fees and terms and conditions of occupancy. As recommended at the last inspection, the contract has been updated to include the room number to be occupied. All five people who completed comment cards for the Commission confirmed that they had received a contract. Care Homes for Older People Page 11 of 30 Evidence: Two people who had recently moved to the home told us that they had been given the opportunity to visit the home before making a decision to move there and that their families had also been involved in this process. The homes AQAA said that people are encouraged to visit the home for the day to enable them to experience life at the home. Five people using the service completed comment cards for the Commission and all confirmed that they had received enough information about the home to enable them to make an informed decision about living there. We were able to see evidence that people had been appropriately assessed by the home before being offered a placement. Pre-admission assessments and assessments from other health care professionals available in the care plans examined. The homes completed AQAA stated that people are encouraged to have a trial period at the home before making a decision to move there. Care Homes for Older People Page 12 of 30 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. Peoples care needs are set out in their plan of care and there are plans to further improve the care planning documentation. People told us that their care needs were met. The home follows the correct procedures for the management and administration of peoples medication. People are treated with respect and their right to privacy is upheld. Evidence: We examined two care plans at this inspection. These contained up to date information about the individuals assessed needs. We were informed by the acting manager that they were in the process of changing to a new care plan format which will provide clearer and more detailed information. This is felt to be positive as, although care plans examined contained adequate information to enable staff to meet peoples needs, more emphasis needs to be placed on involving people in the care planning Care Homes for Older People Page 13 of 30 Evidence: process and including peoples preferences so that a more person centred approach to care can be promoted. Care plans contained evidence that people have access to appropriate health care professionals. The home monitors peoples weights on a monthly basis and any significant changes are recorded. We were able to see that care plans had been raised where required, to address nutritional needs. During this inspection we were able to speak with 18 people living at the home. All confirmed that they felt well cared for and that staff treated them with dignity and respect. People told us that the enjoyed living at the home and staff always respected their wishes/preferences. We were able to observe staff interactions with people. We heard staff communicating with people in a kind and respectful manner. People appeared comfortable and relaxed in the presence of staff and the management team. We observed staff knocking on peoples bedroom doors before entering. People said that the staff respected their privacy. Five people completed comment cards for the Commission and in response to the question; Do the staff listen and act on what you say, all responded Yes. They are very caring and helpful, They do what they can but they are very busy. People confirmed in comment cards that they received the medical support they needed. We examined the homes procedures for the management and administration of peoples medication. The home uses the Boots monitored dosage systems (MDS) with pre-printed medication administration records (MAR). We examined all available MAR charts and these were seen to be appropriately completed. Records of medicines received into the home and returned to the pharmacy are maintained and all transactions had been confirmed by two staff signatures. MAR charts contained a photograph of each individual and sample signatures were in place for all staff authorised to administer medication. All medicines were seen to be securely stored and no excess stocks were apparent. Daily records for the fridge and room temperatures are maintained to ensure that temperatures remain within acceptable limits. We were informed that all staff involved in the management and administration of medication have received appropriate training and on-going supervisions to ensure competence. This was also confirmed by staff spoken with during the inspection. Correct procedures were being followed relating to controlled drugs at the home. Care Homes for Older People Page 14 of 30 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. The home have taken steps to ensure that people are offered a varied programme of activities and this has had a positive outcome for people living at the home. People choose when and where to see their visitors and the home ensure that visitors are made to feel welcome. The home ensures that people are offered a wholesome and varied diet. Evidence: At the last key inspection it was required that the home ensure that people are offered appropriate activities. The homes completed AQAA identified the homes intentions to improve this area for people living at the home. At this inspection we were able to see a marked improvement. The home has employed an activities co-ordinator who has devised a weekly activity programme based on the views of the people living there. When we asked people living at the home about the activities available, they were very positive and keen to tell us how much this had improved; There is something going on every morning and afternoon, We recently had a coffee morning which I really enjoyed, We have a trip out every week and they make sure that we all get the Care Homes for Older People Page 15 of 30 Evidence: chance to go if we want to, I used to spend a lot of time in my room as there was nothing going on but now I am downstairs all the time. On the morning of this inspection, the activities co-ordinator was facilitating a word game for people in one of the lounges. This was very well attended and everybody was actively joining in. People told us that they had really enjoyed this activity; It keeps my brain active. Each person spoken with had nothing but praise for the activity coordinator; He is just wonderful, He has changed my life, so enthusiastic, There is so much to do now. We received five completed comment cards from people using the service. Four felt that there were usually activities that they could take part in and one responded always. They also made the following comments; There are more activities since the new owners have taken over and more are planned, A varied programme of activities now takes place, More activities now we have new owners. We were able to speak with the activity co-ordinator during the inspection and his commitment and enthusiasm were very apparent. The activity co-ordinator maintains very detailed records relating to each activity which include information about the outcomes for the individuals taking part. In order to comply with data protection requirements, we discussed the need to ensure that individual records are maintained for each person rather that recording outcomes for more than one person as they are currently doing. We were informed that this had already been discussed with the person responsible and that records are currently being reviewed. People told us that their visitors were always made to feel welcome and were always offered refreshments. People told us that they could choose where to see their visitors and could use the privacy of their own bedroom if they wished. People told us that were able to make choices about how and where to spend their day. Many people were seen to be utilising the communal lounge areas during the day though some had chosen to spend time in their bedrooms. People told us that they were able to make choices about what time they get up or go to bed. They also told us that the staff know what time I like to go to bed, They know that I wake early and they bring me a cup of tea. We were informed that the home employs catering staff covering a seven day period. All meals are prepared and cooked at the home. We were able to view a four week menu which appeared wholesome and varied. Two options were available for each meal. People living at the home told us that they are asked about their choices each morning. We were able to see that records relating to this were maintained. Care Homes for Older People Page 16 of 30 Evidence: During this inspection we were able to see lunch being served. The majority of people went to the dining room for lunch. The dining room is very spacious and tables were noted to be attractively laid. Napkins and condiments were available and people had access to hot and cold drinks. The meal was served by staff from a heated trolley. Portions were generous and the meal looked appetising. People were positive about the meals at the home and told us that there was plenty to eat. Some people felt that the teatime choices could be improved as they were a little dull. We discussed this with the registered person and acting manager and it was agreed that this would be raised at the residents meeting the next day. Five people completed comment cards for the Commission and in response to the question, do you like the meals at the home, two responded usually, two sometimes and one always. There could be more variation at tea time, the meals have improved but they could be better, the food is lovely. Care Homes for Older People Page 17 of 30 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 systems in place to allow people to raise concerns and it ensures that all concerns are appropriately investigated. Procedures are in place to reduce the risk of harm or abuse to the people living there. Evidence: The home displays a satisfactory complaints procedure. People told us that they would feel confident in raising concerns if they had any. This was also confirmed in the comment cards received by the Commission. They said that they found the staff and management team very approachable. Nobody raised any concerns with us at this inspection. The home maintains appropriate records relating to concerns received. We were able to see that the two complaints received within the last 12 months had been appropriately investigated within the agreed timescales. The home has procedures in place to ensure that people are not placed at risk of harm or abuse. Robust staff recruitment procedures include checks with the Criminal Records Bureau (CRB) and Protection of Vulnerable Adults list (POVA). The home also has a range of policies and procedures available for staff which include accepting gifts, managing challenging behaviour and whistle blowing. Staff spoken Care Homes for Older People Page 18 of 30 Evidence: with at this inspection told us that they would feel confident in raising concerns if they had any. All were able to demonstrate an understanding of the correct procedures to be followed. Staff told us that they had recently received training in abuse and the protection of vulnerable adults. The home has a revised copy (May 2007) of Somersets policy on Safeguarding Adults. A copy was also seen to be displayed in the staff room. Care Homes for Older People Page 19 of 30 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 live in a comfortable and homely environment. A refurbishment plan is in place and is on-going and people have benefited from the improvements made so far. People have their own bedrooms which they can personalise. The home has a range of appropriate aids and adaptations to assist the people living there. The home follows appropriate procedures to reduce the risk of the spread of infection. Evidence: Since the last inspection the home has undergone an extensive refurbishment and redecoration programme which is on-going. People living at the home were very positive about the improvements made so far. New carpets have been fitted to all communal areas and corridors, areas have been decorated and lighting fittings have been changed. A number of bedrooms have been refurbished and fitted with new carpets. The homes completed AQAA stated that bedrooms are redecorated when they become vacant so as to cause as little disruption to people as possible. A new call bell system has been installed. Care Homes for Older People Page 20 of 30 Evidence: During this inspection we viewed all communal areas and a selection of bedrooms. All areas were noted to be warm and comfortably furnished and people appeared relaxed in their surroundings. The standard of decor and furnishings were noted to be good and gave an overall homely feel. As previously mentioned, people spoken with were very positive about the environmental improvements made at the home; Since the new owners have been here things have improved, We have new carpets, paint and better lighting, They are very caring and have done a lot to make the home a more pleasant and homely place to live. Bedrooms appeared very comfortably furnished and people told us that they were very happy with their rooms. Call bells were within easy reach and people said that staff responded to call bells promptly. Bedroom doors are fitted with locks which can be accessed by staff in the event of an emergency. Windows above ground floor level have been restricted to ensure peoples safety and radiators have been fitted with a guard. Grab rails are appropriately sited throughout the home to aid mobility. A shaft lift gives access to the first floor. The home has two assisted bathrooms and one mobile hoist. We were informed that there were no people currently at the home who required two staff to mobilise. Wheelchairs are regularly serviced and we saw that a number of people mobilised using their own walking frames. The laundry facilities were viewed and appropriate infection control measures were in place. We were informed that staff currently carry out the laundry duties. Staff told us that they did not experience any problems carrying out this role. Four people spoken with expressed some dissatisfaction with regard to the laundry. They said that personal items were always going missing, the standard of ironing was poor and that towels are very rough. This was discussed with the management at the time of the inspection who agreed to look into. We were informed that they had recently taken action to ensure that personal items do not go missing. The home employs domestic staff to cover a seven day period. At the time of this inspection the standard of cleanliness was noted to be very good. Staff hand washing facilities are appropriately sited throughout the home and staff have access to protective clothing. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels are appropriate to the needs of people currently at the home. The homes procedures for staff recruitment reduce the risk of harm or abuse to the people living there. The home has procedures in place to ensure that staff have the skills and training to meet the needs of the people living there. Evidence: At the time of this inspection 28 people were living at the home. We were informed that minimum staffing levels were as follows; AM - 1 senior carer and 3 carers PM - 1 senior carer and 1 carer evening - 1 senior carer and 2 carers Night - 1 waking and 1 sleep-in carer We were informed that the acting manager, who works Monday to Friday and the deputy manager who works Monday, Wednesday and Friday, were on duty in addition to the care hours shown above. Management support is also provided by the responsible individual and a company representative who are frequently at the home. The home also employ domestic, catering and activity staff. Care Homes for Older People Page 22 of 30 Evidence: When we asked staff about staffing levels at the home they told us that they did not experience any difficulties in meeting peoples needs. People living at the home told us that the staff were available when they needed them and that call bells were responded to in a timely fashion. People also told us that they felt their needs were met by staff. We were informed that the home have not had to use agency staff to cover any shortfalls. The homes completed AQAA told us that of the 20 permanent care staff employed, 13 have a minimum of an NVQ Level 2 in care. This equates to 65 which exceeds the recommended 50 of the National Minimum Standards. The AQAA also told us that 1 carer is currently working towards this award. We examined the homes procedures for staff recruitment. Recruitment files for three staff recently employed were viewed. These contained all required information including evidence of enhanced criminal records checks (CRB) and protection of vulnerable adults checks (POVA). We were able to see evidence that staff had not commenced employment until receipt of satisfactory references and POVAFirst checks had been received. We were informed that, where staff commence employment on a POVAFirst pending a full CRB, they are supervised at all times. Examples were provided to support this. As this is not formally documented, it has been recommended that in these situations, the home documents all restrictions and the arrangements that will be put in place to supervise the staff member during this period. This should be signed by the home and the employee. It has also been recommended that the application for employment form prompts staff to provide a 10 year employment history. Recruitment records contained evidence that staff had been supplied with a job description and copy of the GSCC code of conduct. The home have produced a training plan for staff and we were informed that all staff have received mandatory training. This was confirmed by the staff spoken with during the inspection. Staff also told us that they had recently received training in the protection of vulnerable adults. Thirteen staff have a first aid certificate. All staff spoken with during the inspection said that they felt that they had the skills and training necessary to enable them to meet the needs of people living at the home. Staff recruitment files examined contained evidence that staff undertook a five day induction programme on commencing employment. We were provided with a staff induction book which is completed over the following 12 weeks of employment. This appears to meet with the Skills for Care Common Induction Standards though we Care Homes for Older People Page 23 of 30 Evidence: found that there was nowhere available to sign staff off as competent in each area. This was discussed with the management team at the time. Care Homes for Older People Page 24 of 30 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. Satisfactory arrangements are in place to ensure that the home is effectively managed in the absence of a registered manager. The home has effective systems in place to seek the views of people using the service, their representatives and other stakeholders. The home has procedures in place to ensure the health and safety of persons at the home. Evidence: In the absence of a registered manager, standards 31 and 32 could not be fully assessed at this inspection. The registered manager has recently left this post and the registered provider has made arrangements for the home to be effectively managed during this period. An experienced acting manager is now in post and this person will be submitting application for registration to the Commission. The registered provider Care Homes for Older People Page 25 of 30 Evidence: and a company representative have been providing management cover and support in the absence of a registered manager. During this time staffing structures have been reviewed to ensure that appropriately trained senior care staff are on duty at all times. People spoken with during this inspection told us that they had been kept informed during this period. They told us that they found the registered person, company representative and the acting manager approachable. Staff spoken with did not express any concerns about the management of the home or of the support they received. The home has effective quality assurance procedures in place which seek the views of people using the service, staff, relatives and other stakeholders. Regular meetings are held for staff and this has also been implemented for people using the service. Questionnaires are sent to people using the service, relatives and health care professionals on an annual basis. We were able to view 11 completed questionnaires received from relatives for the survey conducted in October of this year. Comments were very positive and many had acknowledged the improvements made to the homes environment, call bell system and activities. All confirmed that they were satisfied with the care their relative received; The home is friendly and relaxed, A caring and friendly home and visitors are made to feel welcome. There was a general consensus that the laundry arrangements could be improved. The home is in the process of developing an annual newsletter which will be made available to people using the service and their representatives. As part of the homes quality assurance programme and in line with the Care Home Regulations 2001, the registered person conducts monthly visits to the home. Written reports were available at the home. We were informed that the home do not manage any monies on behalf of the people living there. The home has arrangements in place for an individuals representative to be invoiced as appropriate. Recruitment records examined at this inspection contained evidence that staff were receiving formal supervisions. The acting manager confirmed that she had systems in place to ensure that all staff receive formal supervision at least six times a year. Staff spoken with during this inspection were positive about the support they received. We examined the homes procedures relating to health and safety and our findings were as follows; Care Homes for Older People Page 26 of 30 Evidence: FIRE SAFETY - The home has a fire risk assessment which was reviewed in October 2008. In-house checks and annual servicing records were up to date. Training records indicated that staff have received up to date training in fire safety. This was also confirmed by staff spoken with. GAS SAFETY - An up to date annual servicing certificate was in place. ELECTRICAL SAFETY - The home has an up to date electrical hardwiring certificate dated 21/03/08 and valid for 5 years. Annual testing on portable electrical appliances was last carried out in November 2008. EQUIPMENT SERVICING - We were informed that the home has 2 bath hoists and 1 mobile hoists. The home has contracts in place to ensure that these are serviced twice a year. This is also the case for the homes shaft lift. Records confirmed that wheelchairs had been serviced by an external contractor in April 2008. HOT WATER OUTLETS/SURFACES To reduce the risk of burns/scalds, radiators are fitted with a guard and hot water outlets are fitted with a thermostatic control. Monthly checks are carried out by the home to ensure that hot water temperatures do not exceed safe upper limits. The Environmental Health Dept conducted an inspection on the homes kitchen on 05/08/08 where they awarded the home a 4 star Very Good rating for its food hygiene standards. Care Homes for Older People Page 27 of 30 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 28 of 30 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 14 The home should ensure that records relating to activities are recorded for each individual and not as a group, so as to comply with the Data Protection Act 1998. The homes application for employment should be revised so that it prompts applicants to provide a 10 year employment history. Where an employee commences employment on a POVAFirst, pending a full CRB, the home should ensure that any restrictions and the arrangements for supervising the individual, are fully documented and signed by the employee and the home. The staff induction programme should include the provision of sheets which enable the home to verify when the employee is deemed competent in each area. 2 29 3 29 4 30 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. 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