Inspection on 20/11/08 for Summer Lodge

This inspection was carried out on 20th November 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Summer Lodge 29/05/08

Summer Lodge 30/11/07

Summer Lodge 01/05/07

Summer Lodge 19/04/06

Summer Lodge 28/11/05

Summer Lodge 23/06/05

Summer Lodge 14/12/04

Summer Lodge 09/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

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 27/02/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Sackville Nursing Home 2-4 Sackville Road Hove East Sussex BN3 3FA     The quality rating for this care home is:   one star adequate 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: Jennie Williams     Date: 2 7 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 © (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: Sackville Nursing Home 2-4 Sackville Road Hove East Sussex BN3 3FA 01273-775577 Telephone number: Fax number: Email address: Provider web address: sackville@vigcare.com Name of registered provider(s): Name of registered manager (if applicable) Mrs Linda Marian Frances Geraghty Type of registration: Number of places registered: Mrs Beant Kaur Vig,Mr Joginder Singh Vig care home 28 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 to be accommodated is 28. The registered person may provide the following category/ies of service only: Care home with nursing - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP). Date of last inspection Brief description of the care home Sackville Nursing Home is a care home registered for twenty-eight (28) places for residents, of either gender, aged sixty-five (65) or over. Nursing care is provided at the home. The Registered Providers own several care homes throughout the South of England, predominantly older people services. The home is located in a residential area of Hove. There are local amenities in the area and there is nearby access to public transport. There is no parking available at the home and restricted paid parking in Care Homes for Older People Page 4 of 30 Over 65 28 0 Brief description of the care home adjacent streets. There are twelve (12) rooms for single occupancy, of which five (5) have en suite facilities. There are eight (8) double rooms, of which one is provided with en suite facilities. Rooms are located over three floors. There is a passenger shaft lift that assists residents to access all areas of the home. There is a lounge area on the ground floor. There is a garden at the rear of the building that is accessible to residents. There are suitable numbers of toilet and bathing facilities located throughout the home to meet the needs of residents. Fees range from 490 pounds to 600 pounds per week. Additional fees are: hairdressing, chiropody, toiletries and newspapers/magazines (at cost). This information was provided to the CSCI on the 27 November 2008. Additional information regarding additional costs is provided in the Service Users Guide. 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: one star adequate 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: It should be noted that following recent CSCI consultation, it was identified that service users prefer to be called people who use services. It was confirmed that the home uses the term residents. For the purpose of this report, people who use the service will be referred to as residents. This unannounced site visit took place over two days for a total of nine and three quarter hours. This included a site visit to head office to check residents finances. Evidence obtained at this site visit, previous information regarding this service and information that the CSCI have received since the last inspection forms this key inspection report. The last key inspection was undertaken on the 29 May 2008. Care Homes for Older People Page 6 of 30 Ten resident surveys were sent to the home prior to the site visits, of which five were received. Six residents were spoken with throughout the site visit. The quality review nurse, from the local authority, was undertaking an audit of the documentation and procedures in place on the day of the first site visit. The Registered Manager agreed for this report to be shared with the Inspector. At the time of writing this report, the information was not available. Specific areas of care were viewed in approximately ten care plans. The Inspector viewed a care plan with an individual, at their request. Two visitors were spoken with at the site visit. The Registered Manager and five staff were spoken with throughout the site visit, including carers and registered nurses, activities person and the cook. Ten staff surveys were sent to the home prior to the site visit, of which two were returned. Three staff files were inspected, along with training records. A tour of the environment was undertaken and some individual rooms were viewed. Medication procedures were inspected. The quality assurance system was discussed, some recent results viewed and complaint records were viewed/discussed. There were eighteen residents residing at the home on the day of the site visit. What the care home does well: What has improved since the last inspection? What they could do better: The documentation in place for some people does not fully reflect the level of care provided and there is a risk that care may not be consistently provided. Clear and up to date information pertaining to individuals must be maintained to evidence that the home is meeting the needs of residents. Risk assessments for the use of bed rails need detailed information, be specific to the individual and provide guidance if the use of bed rail covers are required or not. This will assist in promoting residents safety. Confirmation needs to be obtained that the controlled drugs cabinet complies and is installed in line with current guidelines. Records relating to individuals needs to be kept up to date and stored securely to promote confidentiality and ensure residents best interest are safeguarded. Care Homes for Older People Page 8 of 30 The Registered Manager needs to be provided with a job description that enables her to take responsibility for fulfilling her duties and there are clear roles and responsibilities within the home and with external management. Other shortfalls noted where no requirement or recommendation has been made are reflected throughout the content of the report, of which the Registered Manager will ensure she addresses or has confirmed have already been addressed. This service has previously had outstanding requirements and has had a large amount of regulatory input. It is now for the service to demonstrate that it is able to sustain improved outcomes. 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 home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. The pre admission process ensures that only residents whose needs can be met at the home are admitted. Evidence: The home has a Statement of Purpose and Service Users Guide available to provide prospective residents/representatives about the facilities and service provided at Sackville Nursing Home. All resident surveys received identified that they received enough information about the home before moving in so they could decide if it was the right place for them. One newly admitted resident confirmed that they received no information about the home and was not in a position to visit the home prior to admission. Care Homes for Older People Page 11 of 30 Evidence: The Registered Manager confirmed that she undertakes an assessment of all residents prior to admission. There was evidence of this in place at the home. Copies of social services care plans and information from other health professionals is obtained wherever possible. A registered nurse undertakes another assessment with the resident upon arrival at the home and commences to devise the care plan with the individual, wherever possible. Staff spoken with confirmed that they felt all residents were appropriately placed at the home with all needs being met. They stated that appropriate action is taken if someones needs can no longer be met at the home. The Registered Manager confirmed that there is no resident at the home from any minor ethnic community, social/cultural or religious groups with any specific needs or preferences. Prospective residents/representatives are encouraged to visit the home prior to admission. The home takes emergency admissions. There is no dedicated accommodation to provide intermediate care, however respite is available if there is a spare place available. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff practice reflects an understanding of residents personal and healthcare needs, however the documentation in place for some people does not fully reflect the level of care provided and there is a risk that care may not be consistently provided. Evidence: The quality review nurse was undertaking an audit of the care plans and other documentation/procedures within the service. The Registered Manager agreed for this information to be shared with the Inspector. At the time of writing this report, this report was not available. Specific areas of care viewed identified that care plans generally provided guidance to staff on the needs of residents, however further work is required. Discussions were had with the Registered Manager on ways to improve the information. An example is, where someone is on monitoring charts for pressure relief or to monitor intake of food/fluids, this should be identified in the care plans. The Inspector went through a care plan with an individual who confirmed that the information was reflective of their Care Homes for Older People Page 13 of 30 Evidence: needs. There was evidence that one resident did not want to be involved in their care plan reviews. Turning charts and fluid balance charts were in use however were not reflective of the level of care that staff confirmed they provided. Some charts identified that an individual had not been turned for a period of 13 hours and had not been provided anything to eat or drink for up to eight hours. When visiting on the second day, it was observed that additional information had been added to the monitoring charts. Information should be recorded at the time care is provided as information added up to a week later would not be accurate. Information documented in turning charts and fluid balance charts used for monitoring care must be improved and consistent. (Turning charts - used for people who have limited movement and are at risk of developing pressure areas. Fluid balance chart - used to monitor the intake and/or output of an individual). Whilst recording some peoples food/drink intake, there was no evidence to identify how this information was being used/analysed to monitor the well being of the individual. The Registered Manager has commenced developing care plans with pre-populated information. Discussions were had regarding the information these contained and were not always relevant to the individual or provided clear guidance on the level of care provided. Using pre populated care plans runs a risk of care not being person centred and care becoming task orientated for staff. Whilst touring the environment, it was observed that pressure relieving mattresses were not set to the correct setting. Incorrect setting results in pressure relieving equipment not being used effectively. Fortunately, at this time, no resident had any pressure damage resulting from this. Written confirmation was provided the day following the second site visit that all mattresses have been checked and are being used as per manufacturers guidelines. Bed rail risk assessments were seen to be in place for some individuals, however the information in these needs to be improved. Evidence needs to be provided for why covers on bed rails are not in use and that this does not pose a risk to the safety of the individual. These risk assessments need to be more detailed, specific to the individual and identify if bed rail covers require to be in place. The quality review nurse viewed medication procedures prior to the Inspector viewing the procedures. The quality review nurse identified that hand written prescriptions were not double signed and one hand written prescription was not signed at all. The Registered Manager and a registered nurse addressed this shortfall before the Inspector viewed medication procedures. One prescription viewed did not identify if Care Homes for Older People Page 14 of 30 Evidence: the medicine needed to be given regularly or as needed (PRN). The Registered Manager will address this. Medication Administration Records (MAR) and blister packs viewed identified that medicines were being signed for at the time of administration. For someone on regular pain relief, staff are scoring the level of pain for the individual and this information is shared with the GP so that the best combination of pain relief can be prescribed. Where a prescription states do no give if systolic is less than 100, referring to blood pressure, nurses were not recording the blood pressure reading. The Registered Manager confirmed that they would record if the systolic is below 100. It is recommended that staff record when they take the blood pressure to evidence that this is being done prior to administration. There were accurate records being maintained of controlled drugs. The home needs to obtain confirmation that the controlled drugs cabinet complies and is installed in line with the current legislation. Of the residents that were asked, all confirmed that they felt their privacy and dignity were respected. Staff were observed to have a good professional rapport with the residents and were heard to be calling them by their preferred term. New screening has been placed in the double rooms. These were observed to be slightly see through during the day and would be more see through at night with a light on, reducing the individuals privacy when being assisted with any personal care. The Registered Manager confirmed that she will address this. 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. Residents lifestyles within the home are their own choice and are provided with sufficient stimulation to fulfil their interests and needs. Residents receive a choice of balanced and freshly prepared meals. Evidence: Of the residents that were asked, all confirmed that their lifestyle is generally their own choice. One confirmed that she chooses when to have a bath/shower and another confirmed that they choose when to go to bed. Records identified that some individuals leave the home independently to visit friends, family or the community. There is an activities person employed at the home for three days a week for four hours. Staff also initiate activities within the home. The home has just commenced booking entertainers to visit the home. This had been stopped by head office due to the restrictions of admissions imposed on the home by the CSCI, that have since been lifted. No one at the home could confirm how long entertainers had been prevented from visiting the home, however confirmed this was ceased due to financial restrictions. Care Homes for Older People Page 16 of 30 Evidence: Residents spoken with confirmed that there are activities provided at the home should they choose to be involved. The home has now been able to locate a visiting hairdresser to visit the home on a regular basis. The activities person felt that things are improving now they are getting more residents. There are no visiting restrictions at the home and a visitor spoken with confirmed that they are made welcome when visiting the home. Residents are taken out into the community, assisted by the activities person or care staff at the home. A new cook has commenced employment at the home and staff and residents were complimentary about the food being provided. All resident surveys received identified that they always like the meals that are provided. Residents have a choice in meals. Comments received from staff and the residents about the food ranged from OK , very nice and have choice and best chef ever. It was confirmed that the home received 4 scores on the door from Environmental Health in January/February 2008. A staff member was observed offering discreet assistance to an individual who required assistance with feeding. The majority of residents eat from table trays in the lounge room or in their bedrooms. A table and four chairs have been provided to make a small dining area, however staff confirmed that this is not well used. Staff commented that having chairs with arms on them may assist with this area being put to better use. Management needs to consider this. Residents are able to choose where they wish to eat. 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. Residents feel comfortable to complain, reassuring them that they are being listened to and that action will be taken, if necessary. Residents are safeguarded by the procedures in place for Safeguarding Adults. Evidence: The home has a complaints procedure available and four surveys received from residents identified that they know how to make a complaint. Records were viewed for three complaints raised with the home. Two were related to care issues, of which one was upheld and one was unsubstantiated. Records viewed identified that the home takes action where necessary to resolve complaints. One concern had been addressed with the CSCI, however the individual was happy to deal with this through the homes complaint procedure. This was related to financial matters and was being dealt with by the homes head office. Records were viewed and copies of all correspondence are kept. This complaint has not yet been concluded. The Registered Manager will be keeping a central log of complaints. Both staff surveys received identified that they know what to do if a resident/relative/advocate or friend raises concerns about the home. The Registered Manager confirmed that staff undertake external training in Safeguarding Adults every year. Basic Safeguarding Adults training is provided in Care Homes for Older People Page 18 of 30 Evidence: house for new staff until they can be booked onto an external course. There has been one Safeguarding Adults alert regarding physical abuse raised since the last inspection. This was dealt with through the multidisciplinary procedures and the outcome was unsubstantiated. Action has been taken to reduce the risk of the allegation being raised again. The home has information regarding the Mental Capacity Act available for staff. 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. Work is continuing to be undertaken to ensure residents live in a homely environment and are provided with comfortable indoor communal facilities. Evidence: Work has been done and is continuing to be done to improve the environment within the home. The Registered Manager will be implementing a new maintenance/refurbishment programme for next year. On touring the environment, it was observed that some furniture is in need of being thoroughly cleaned or replaced. The Registered Manager confirmed that five new hospital beds have been purchased and are in the process of purchasing new bed tables. New armchairs will be purchased over time. It was observed that some communal bathrooms were being used as a storage area, preventing the bathrooms from being used independently by residents. The Registered Manager confirmed that the residents residing near these bathrooms were unable to use the facilities independently. The home was generally clean throughout, however any areas identified that were needing attention was reported to the Registered Manager who will ensure they are Care Homes for Older People Page 20 of 30 Evidence: addressed. The cleaner records her activities/duties undertaken. It was noted that some bathrooms did not have a bin present, or had bins with no lid. It was recommended that pedal bins with lids be provided to promote infection control. The Registered Manager verbally confirmed to the Inspector following the site visit that this has been addressed. All five resident surveys received identified that they always find the home fresh and clean. 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. Residents needs are being met with the skill mix of staff on duty. Recruitment procedures ensure that residents are safeguarded. Evidence: The Registered Manager confirmed that the staffing levels are: two registered nurses (includes Registered Manager) and 2 carers in the morning, one/two registered nurses and two/one carers working afternoon and one registered nurse and one carer work a waking night. The rota was reflective of these staffing numbers. Feedback from staff identified that there were mixed feelings regarding the suitability of staffing numbers currently working. Some felt that there were enough staff on duty, whilst others felt that resident numbers and needs were increasing and feel staffing numbers need to be increased. Residents spoken with felt there were sufficient numbers on duty. For those who felt there could be more staff, confirmed that staff were usually around to offer assistance when needed. No requirement or recommendation has been made in relation to staffing numbers, however management needs to ensure these are kept under regular review. Feedback from residents about the staff working at the home were quite alright to very good. Care Homes for Older People Page 22 of 30 Evidence: There is currently eight care staff (excluding registered nurses) employed, of which four have National Vocation Qualification (NVQ) level 2 or above. An additional three staff are undertaking NVQ training and one carer is waiting to commence this course. Three staff files viewed identified that suitable recruitment procedures are followed. All files were seen to have application forms, references and Protection of Vulnerable Adults (POVA) First checks and enhanced Criminal Record Bureau (CRB) checks in place. One staff had commenced employment prior to a full CRB check having been returned. The Registered Manager confirmed that this person had worked supervised until the CRB was returned. Feedback from staff confirmed that there are enough training opportunities provided at the home and they are kept up to date with mandatory training. Registered nurses receive additional training relevant to their roles. The Registered Manager provides some in house training to staff. The Registered Manager maintains a training matrix. Some recent training undertaken in house by new staff were infection control, Basic Safeguarding Adults, Basic fire training and Control of Substances Hazardous to Health (COSHH). There was evidence in a staff file that the Common Induction Standards, as set by Skill for Care, is implemented for new staff. Care Homes for Older People Page 23 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a Registered Manager and there are procedures in place to ensure the home is run in the best interest of residents. Residents are not always safeguarded by the homes record keeping. Evidence: There is a Registered Manager in post who is registered with the CSCI. She confirmed she has current registration with the Nursing and Midwifery Council (NMC) and has completed the Registered Manager Award course. She confirmed that she keeps herself up to date with current practices by attending training courses, CSCI website, reading relevant literature and through manager meetings. Clinical supervision is provided by other staff employed by the registered providers at another of their establishments. The majority of staff were complimentary about the Registered Manager with one commenting that they find her approachable and supportive. Other feedback identified Care Homes for Older People Page 24 of 30 Evidence: that there could be better communication with the Registered Manager. No requirement or recommendation has been made in relation to this, as this is an area for the home to resolve internally. Feedback provided to the Inspector identified that staff were questioned individually following some negative comments reflected in the previous report regarding the management of the service. This appears that there is a blame culture within the home, whereby information should be used positively to assist staff and management to improve the service and ethos within the service. The Registered Manager confirmed that she is not always able to take the time allocated to her for management time. It was discussed with her and a representative from head office that management time be reflected accurately on the rota and the Registered Manager ensure that she uses the time allocated for management duties. It has been confirmed that when more residents are admitted to the home, she will work full time management duties. The Registered Manager has not yet received a new job description for her role. The Registered Manager confirmed that Regulation 26 visits are being undertaken. The report for November was seen, however others were inaccessible due to the filing cabinet drawer being locked and unable to be opened. There is a quality assurance and quality monitoring system in place. Quality assurance surveys are sent twice a year to staff, residents, relatives and visitors. Other stakeholders are requested to complete a survey when they visit the home. Surveys for the last quality monitoring surveys have just been completed. Discussions were had with the Registered Manager on ways to analyse information and display results for people who have an interest within the service to view. It was confirmed that health and safety checks are undertaken monthly. The Registered Manager confirmed that action points from their previous action plan have all been implemented. Residents monies are held at head office of the registered providers. Procedures and records viewed identified that suitable measures are in place to monitor residents personal allowances, ensuring residents are safeguarded. Measures are being taken to have this money be stored and monitored at the home. A registered provider is an appointee for three or four residents. Action is being taken to make arrangements for other people, not associated with the home, to take over the managing of these finances. Records used by staff to record individual care provided to residents need to be kept securely. Other shortfalls relating to record keeping in relation to residents Care Homes for Older People Page 25 of 30 Evidence: information can be found in Health and Personal Care. The Inspector was able to enter the lounge room and view personal information about residents. There were no staff present in the lounge room at this time. Action needs to be taken to ensure that information is kept securely to assist in promoting confidentiality. Health and safety records were not viewed. It was confirmed that staff undertake regular fire training and fire drills. An external company undertakes a fire risk assessment. The Registered Manager confirmed that equipment in use has been tested or serviced as recommended by the manufacturer or other regulatory body and that all relevant policies and procedures are in place. Care Homes for Older People Page 26 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 27 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 7 15 That care plans reflect clear information and records pertaining to individual needs are maintained, kept up to date and all care provided be accurately recorded and person centred. This is to evidence that the home is meeting the needs of the residents. 30/01/2009 2 7 13 That clear person centred 30/01/2009 risk assessments are in place for the use of bed rails and bed rail covers. This will assist to promote residents safety. 3 9 13 That advice be sought and confirmation obtained that the controlled drugs cabinet is suitable and installed correctly. to ensure compliance with current guidelines. 03/04/2009 Care Homes for Older People Page 28 of 30 4 37 7 That records pertaining to individuals are kept up to date and stored securely. To ensure service users best interests are safeguarded and confidentiality is promoted. 30/01/2009 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 1 31 That the Registered Manager is provided with a job description that enables her to take responsibility for fulfilling her duties and there are clear roles and responsibilities within the home and with external management. 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. 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