Inspection on 23/01/09 for Pilgrim Wood

This inspection was carried out on 23rd January 2009.

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

Pilgrim Wood 26/01/07

Pilgrim Wood 05/12/05

Pilgrim Wood 09/08/05

Pilgrim Wood 29/12/04

Pilgrim Wood 07/09/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings 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: Pilgrim Wood Pilgrim Wood Sandy Lane Guildford Surrey GU3 1HF     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: Suzanne Magnier     Date: 2 3 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 30 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 30 Information about the care home Name of care home: Address: Pilgrim Wood Sandy Lane Pilgrim Wood Guildford Surrey GU3 1HF 01483573111 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Jean Ann Walker,Mr John Albert Flexer Name of registered manager (if applicable) Mrs Margaret Wood Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 35. The registered person may provide the following category 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: Old age, not falling within any other category - (OP) Dementia - (DE) Date of last inspection Brief description of the care home Pilgrim Wood is located in an elevated position overlooking the North Downs within a few miles of Guildford town centre. The home provides accommodation and care for up to 35 older people, 6 of who may also have dementia. The accommodation is arranged over 4 floors, with the first and second floors being reached by stairs or passenger lift, Care Homes for Older People Page 4 of 30 care home 35 Over 65 0 35 35 0 Brief description of the care home and the basement by stairs or stair lift. Most bedrooms are located on the ground and first floor, with a small number on the second floor and 2 in the basement. All bedrooms have en suite toilet and hand basin and 5 bedrooms also have a shower fitted. There are ample bathing facilities located on all floors, with most having adapted toilets and baths to assist those with mobility problems. The home has a spacious lounge area that is able to be split into three areas and a large dining room. There are large, well maintained gardens around the home that are fully accessible to the service users, and parking for several cars to the front of the building. 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 Quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The Commission for Social Care Inspection has since the 1st April 2006, developed the way it undertakes its inspection of care services. The inspector looked at and assessed how well the service was meeting all the National Minimum Standards for Care Homes for Older People and has in this report made judgements about the standard of the service. Ms S Magnier Regulation Inspector carried out the inspection, which lasted for seven hours commencing at 10.00 hours and concluded at 17.00. The registered manager Care Homes for Older People Page 6 of 30 represented the service. The CSCI Inspecting for Better Lives IBL involves an Annual Quality Assurance Assessment AQAA to be completed by the service, which includes information from a variety of sources. This initially helps us to prioritise the order of the inspection and identify areas that require more attention during the inspection process. This document was received by CSCI and is referred to throughout the report. Twenty eight residents currently receive care and support at the home and the residents spoken with spoke favourably about the home and the care and support they receive. The information contained in this report was gathered from observation by the inspector, speaking with a number of residents, their relatives who were visiting, care staff, and from information contained within the AQAA. Further information was gathered from records kept at the home and written comments received from residents and others associated with the home. A full tour of the premises was undertaken and documents sampled during the inspection included the homes Statement of Purpose and Service User Guide, care plans, daily records and risk assessments, medication procedures, health and safety records, staff training and recruitment records, and some of the homes policies and procedures. The final part of the inspection was spent giving feedback to registered manager about the findings of the visit. No complaints have been received by the home and the commission have not received any information of concern about the home and no safeguarding vulnerable adults referrals have been made. From the evidence seen by the inspector it is considered that the home would be able to provide a service to meet the needs of clients who have diverse religious, racial or cultural needs. What the care home does well: What has improved since the last inspection? The menus have been reviewed to offer residents a greater choice and take into account peoples wishes and requests. Staffing arrangements have been improved to include a laundry assistant who also has the role of a senior housekeeper, a full time gardener which has promoted residents interests in the garden where they can grow vegetables and flowers, and senior care staff have been employed to work weekends. Day and night staff supervision and support has been strenghtenned with regular staff meetings being held. Two resident bedrooms have been reorganised and decorated with improved facilities for four bedrooms. There has been development of a hairdressing suite, improved Care Homes for Older People Page 8 of 30 bathing and shower facilities,development of a computer room and some double glazing has been fitted. The home have met the previous requirement that all radiators must be covered to ensure peoples safety. 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. The admission and assessment procedures ensure that residents needs are appropriately identified and met. Intermediate care is not offered. Evidence: Three care plans sampled during the inspection contained good information to confirm that the individuals needs had been assessed prior to being admitted to the home. The registered manager confirmed that she undertook the assessments. She demonstrated that she had the appropriate ability and qualifications to undertake the assessment prior to an individuals admission to the home in order to ensure that the homes staff could meet the individuals care and support needs. The registered manager advised that the home works closely with other health care professionals with regard to the pre admission assessments and as much information is gathered about the individuals need prior to the moving into the home. Care Homes for Older People Page 11 of 30 Evidence: Intermediate care is not currently offered by the home. 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. People are offered a good provision of health care and personal support by the home. Care is administered in way that protects the individuals privacy and dignity and the monitoring of risk assessments is maintained to ensure the safety of people in the home. Some medication procedures need strengthenning in order to ensure the welfare and wellbeing of individuals receiving medication at all times. Evidence: The homes care plans and kardex system were sampled for three residents. The plans had been developed from the pre assessment documentation and included the residents care and support needs. The care plans were well written to allow the reader to gain an overview of the residents cultural and ethnic diversity, medical, social and personal care needs and lifestyle preferences. A monthly chart detailing care plan reviews was sampled in residents care plans which confirmed that the registered manager was aware to ensure that all care plans are signed by the resident or their representative, where possible, and that care plans are Care Homes for Older People Page 13 of 30 Evidence: dated, and the plans kept under review to reflect any changes in the residents care and support needs. The care plans and kardex system included each residents health profile, and dietary requirements including screening tools, body weight charts which are monitored regularly to indicate weight loss or gain, skin integrity, safe moving and handling procedures, the residents current mobility, communication and sensory abilities, medication requirements, specialist care, and day and night time choices and preferences. There was clear documented evidence that regular and appropriate health care appointments including visits by the General Practitioner or by visiting the local health care services had been attended. Whilst speaking with residents it was evident that the home maintains good working partnerships with health care professionals which include visits from the district nurses, physiotherapists, chiropodists, assitance with continence management, speech and language therapists and occupational therapists to ensure that residents health care needs continue to be met. The inspector met with a district nurse who was visiting the home at the time of the inspection who spoke highly of the care and support residents receive. Residents confirmed that they received a good level of support and care from staff and when they were unwell and needed to see a doctor the homes staff were prompt in organising a visit. One resident confirmed that the district nurse visits regularly to attend to their healthcare and that she felt in safe hands. Care records were professionally written and well maintained to reflect the individuals needs and care provided by staff. The risk assessments sampled identified hazards in individuals lives and detailed what actions staff would take to minimise the risk of harm in order to keep the individual safe. The risk assessments were reviewed in order to reflect any changes in the residents care and support needs to ensure their safety and welfare. Other risk assessments were seen and considered to be appropriate in order to promote independence for example walking in the garden whilst ensuring the individuals safety and wellbeing. The home has a medication policy and procedure in place and has been supplied with a monitored dosage system. The senior staff member showed the inspector that the home has good, clear procedures in place for the monitoring and recording of all medicines entering and leaving the home. Records of controlled medication were sampled and checks made were accurate. Some medication administration charts were Care Homes for Older People Page 14 of 30 Evidence: seen which were generally well documented yet it was evidenced that two medication charts contained ommissions on the day of the inspection. This shortfall was promptly addressed by the senior staff member and reported to the regsitered manager. It was confirmed that the two residents had received their morning merdicines yet it has been required that staff must sign to confirm that individuals have received their prescribed medication in order to ensure their safety and welfare. It was noted that some residents were prescribed medication to be given as required. Whilst speaking with the registered manager it was confirmed that there are clear protocols to indicate that all reasonable and safe measures have been taken before the medication has been administered to safeguard the resident and staff from any allegations of harm and abuse. The senior staff member explained that residents have a right to refuse their medication and told the inspector that the home promotes peoples rights to independence and where possible following assessments people would be supported to manage their own medication. The registered manager confirmed that a pharmacist undertakes the homes medication audit in order to ensure procedures are robust and ensure the home has up to date information and are knowledgable about new legislation. Visitors to the home stated that staff members are very caring, kind, welcoming and friendly to residents and visitors. It was observed that residents responded favourably to staff and the staff demonstrated a knowledge and understanding of the residents welfare and support needs. Throughout the day the inspector observed that residents were addressed in a polite and courteous way by staff. Care Homes for Older People Page 15 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. People are able to make choices about their daily routines and enjoy and choose from a range of activities offered by the home. Visitors are welcomed to the home to maintain contact with their family members and friends. The home provides a healthy and balanced diet in a pleasant spacious dining area. Evidence: There was a variety of feedback from residents about the activities programme provided by the home. Some residents told the inspector that it would be nice if staff had more time and were able to sit with them and talk a bit longer than they do now. Residents confirmed that the previous activity organiser had left last year and she was missed by the home. Written comments received by the commission regarding the activities in the home included They should try, although this is not always physically possible, to make them take more exercise, especially in the summer. Larger and more interesting place to walk. I would enjoy to be able to take part in more mentally stimulating activities if other resident were of thie frame of mind. It was observed that staff in the afternoon engaged residents with a quiz which the residents said they really enjoyed doing. The registered manager demonstrated that Care Homes for Older People Page 16 of 30 Evidence: she was aware of the shortfall with regards to planned activities in the home and confirmed that she had recently been advertising for a new activities person yet wanted to make sure that the person recruited would be right for the home and would be able to meet the diverse interests of the people residing at the home. The main lounge was provided with comfortable armchairs and it was noted there was a large selection of books, videos and DVDs, a large television, music centre and a pianno. The home has a mobile shop where people can buy tolietries and confectionary. The home provides people access to a mobile library and links have been maintained with the clergy who are free to visit the home and support residents spiritual and religious needs. A garden party had been held in the summer and residents enjoyed a festive Christmas with visits from family, friends and a local music band. The registered manager confirmed that the home send letters to peoples relatives and friends letting them know what activities are available and forthcoming in the home and a monthly tea at three get together is arranged to assist residents and their families and friends to maintain their links. Photographs of visits to the coast and places of interest were available and the residents said that trips to the theatre are arranged. It was confirmed that residents meetings are held and topics of discussion include planned and purposeful pastimes and interests. Residents have a choice and if they do not wish to attend the meetings their views are sought by requesting they write in advance of the meeting. It was evident through observation that residents are asked if they wish to attend activities demonstrating preference and flexibility of the homes routine. Several residents told the inspector that they enjoyed the visits from the hairdresser and liked the new hairdressing room which has been recently been made available for residents to use. The midday meal served at lunch time was well presented with each resident, where able, being supported to sit up to a dining table to have their meal. The dining room was bright and spacious with appropriate crockery, condiments, napkins and centre piece available on each table. A menu was available in the home for residents to see what was on the days menu and additionally the inspector was told that the home have a spring, summer and a winter menu which incorporates residents choices and the chefs ideas about the food to be served. Care Homes for Older People Page 17 of 30 Evidence: Several residents said that they enjoyed the food served and felt that the standard and quality of food was very good, that there was always plenty and a choice was available. The serving of the meal was professional and staff were attentive to residents during the meal time and meals were served courteously. There was evidence that residents had been given a choice of their meals and a variety of meals were served during the meal time. Staff were available to people who were unwell and who preferred to have their meals in their room. The homes chef met with the registered manager following the main midday meal to give confirmation that residents food intake is monitored and measured in order to ensure that individuals nutritional needs were met. Care Homes for Older People Page 18 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 residents are protected by the homes complaints and safeguarding adults procedures. Evidence: The home has an established complaints procedure. The manager advised that all complaints received by the home are fully investigated and that records are kept by the home to evidence this. Whilst speaking with several residents they confirmed they were aware of how to raise a formal complaint and that they also had resident meetings in which to raise their concerns and views. Written comments received from people associated with the home stated that they knew how to make a complint and it could be difficult if the complaint involved the managers but people knew they could write to the homes owners. It was evident during the tour of the premises that the homes complaints procedures were displayed within the home. The registered manager confirmed that residents receive the complaints procedures with the Statement of Purpose and the Service User Guide in order that residents and other people have access to the policy and procedures so they can raise any concerns, complaints, opinions and views of the homes services which can then be addressed by the home. The home has a copy of the Surrey County Council Multi-agency Procedures for Safeguarding Vulnerable Care Homes for Older People Page 19 of 30 Evidence: Adults. The home has a protection of vulnerable adults policy and procedure which clearly details the lead responsibility role of the local authority multi agency team. Three staff files sampled indicated that safeguarding vulnerable adults training is included within the homes induction programme and several staff spoken with during the inspection confirmed that they would report any allegations of abuse or harm to the manager. The home has a whistle blowing procedure and records sampled indicated that Criminal Record Bureaux checks CRB and Protection of Vulnerable Adult POVA checks are carried out on all new staff prior to them starting work at the home. Care Homes for Older People Page 20 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of maintainece, hygiene and cleanliness within the home is exceptional to enable people who reside at the home to live in a safe and well maintaintained environment. Evidence: The homes environment creates a pleasant home for residents and the facilities are well equipped with aids and adaptations to support people with disabilities and a shaft lift is avaiable. All rooms are fitted with a call bell system in order that residents can summon assistance from staff. Residents spoken with said that they liked their bedrooms, which were viewed during the tour of the premises to be clean, well decorated, furnished with a high standard of furnishings and were personalised. The home has an infection control policy in place and staff are trained and aware in infection control procedures and were observed adhering to infection control measures for example wearing protective clothing, washing their hands and using hand gels to prevent the spread of infection in the home. There is a daily cleaning schedule in place and the home was exceptionally clean and Care Homes for Older People Page 21 of 30 Evidence: odour free throughout, which also included the homes main kitchen. Visitors and residents commented that the standard of cleanliness and hygiene was very good. A handy person is employed to ensure that the home is well maintained. Care Homes for Older People Page 22 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. Staff are in sufficient numbers to support the people who use the service. The homes recruitment, training and induction programmes are robust to ensure that residents are protected from harm and abuse and their needs met appropriately and safely. Evidence: The staffing numbers on the day of the inspection were observed to meet the current needs of the residents and staff were at hand promptly to support residents who required immediate assistance. Visitors to the home on the day of the inspection spoke highly of the staff and how friendly and welcoming the home was. Written comments received by the commission regarding the staffing levels in the home stated there is often a shortage of staff. Agency staff sometimes engaged with some efficient some not which leads to own staff being overworked. The demands of some residents do not help and this is not appreciated by management and I beleive causes friction. There is a shortage of staff which has been acute since Christmas, makes it difficult but essentials are observed. Sometimes there might be a slight delay if the carers are busy. Additional written comments stated There are two or three senior carers who are all very good, they are honest,they listen and act. There is much good will. The Care Homes for Older People Page 23 of 30 Evidence: manager is very keen and should be content. Staff written comments about the home stated The laundry should be improved. Pilgrim Wood is one of the best places I have worked . It was observed that the home employs a multi cultural workforce and equality and diversity issues are addressed within the homes polies and procedures and induction programmes. The inspector sampled four staff recruitment files. The files evidenced that the homes management undertake a safe vetting practice concerning the recruitment of staff in order to ensure the safety and protection of people living in the home. The mandatory training records were sampled and evidenced that there was appropriate evidence to support that staff had undertaken mandatory training courses, additional specialist courses and the homes induction programme in order to ensure they have the necessary skills and knowledge and that they are suitably trained and competent in their duties. The AQAA advises that twelve of the care staff have achieved their National Vocational Qualification NVQ in Level 2 or above. The home had a relaxed atmosphere and staff were observed to undertake their tasks in a quiet and orderly manner. The inspector observed staff interactions with residents all of which were supportive and friendly. 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. The day to day management of the home is robust. Residents are consulted regarding the running of the home and their financial interests are safeguarded. The health and safety of residents is consistent in order to ensure their safety and well being. Evidence: The registered manager demonstrated competency and knowledge in the running of the home and of her role and responsibilities as a registered manager. During the inspection she discussed the needs of the residents and demonstrated a good understanding of differing needs of older people and the support and care required through a person centred approach to care planning. It was observed that her management style was open and approachable and acknowledged that all peoples views and opinions associated with the service should be listenned to and acted upon where appropriate. Care Homes for Older People Page 25 of 30 Evidence: Staff confirmed that the manager was approachable and has a presence in the home and will support staff in all aspects of the delivery of residents care. Records indicated that the manager undertakes night checks and staff confirmed that they can contact the manager if they need to in an emergency. The manager has ongoing support meetings with all grades of staff in order to maintuian the smooth running of the home. Records evidenced that quality assurance processes within the home are undertaken and are part of the service plan for the coming year. Regulation 26 visits records were sampled and the registered manager confirmed that she has direct contact with the directors and any shortfalls identified in the quality of the service would be noted by the directors during the Regulation 26 visits, so that appropriate action could have been taken to rectify the shortfalls. Following the inspection the directors contacted the commission promptly to advise that a door entry system to the main emtrance would be fitted to provide both additional security to the building yet maintain the maximum freedom for residents, their relatives and staff to enter and leave the building. There were clear lines of management accountability during the day of the inspection and staff demonstrated an understanding of their roles and responsibilities. All persons spoken with during the inspection spoke highly of the abilities and knowlegde of the manager and her open approach and the staff morale was good. Some residents financial records were sampled and these were well recorded and clear in evidencing that appropriate safekeeping and regular auditing of the accounts were undertaken in order to safeguard residents from financial abuse. The policies and procedures of the home and organisation were sound and staff demonstrated that they were aware of the core policies and procedures of the home, which included the health and safety policy to ensure that the welfare and safety of all persons in the home is promoted. Records indicated that health and safety checks are maintained, fire safety equipment and records were documented and equipment serviced. The sluice and laundry areas were noted to be clean and tidy. The home have maintained records relating to water temperature checks and robust arrangements are in place to ensure that residents are protected from harm when Care Homes for Older People Page 26 of 30 Evidence: using the bathing facilities. During the tour of the premises it was noted that in a sluice room chemicals had been left by a sink stand and not stored correctly. The chemicals were removed promptly by staff and the home is reminded that all chemicals must be stored in compliance with the Control of Subtances Hazardous to Health COSHH guidance in order to protect residents from harm. The home has the required gas safety and electrical certificates available in the home and a current insurance indemnity certificate. 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 1 13 Arrangements must be made that complete and accurate records must be kept of all medication administered. In order to ensure the safety and well being of individuals receiving their medication. 23/02/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 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 © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!