Inspection on 21/01/09 for South View Lodge

This inspection was carried out on 21st January 2009.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

South View Lodge 24/01/07

South View Lodge 20/03/06

South View Lodge 28/09/05

South View Lodge 08/03/05

South View Lodge 24/08/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: South View Lodge 92 Station Road Hesketh Bank Lancashire PR4 6SQ     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: Julie Playfer     Date: 2 1 0 1 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: South View Lodge 92 Station Road Hesketh Bank Lancashire PR4 6SQ 01772812566 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Bideaway Homes (2) Limited (Mr Thomas Wilson Blane) Name of registered manager (if applicable) Ms Susan Barbara Ball Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The registered person may provide the following category of service only: Care Home only - Code PC To Service Users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old Age, not falling wihtin any other category - Code OP The maximum number of Service Users who can be accommodated is: 30 Date of last inspection Brief description of the care home South View Lodge is registered with the Commission for Social Care Inspection to provide accommodation and personal care for up to 30 older people. The home is situated in a semi-rural location close to the village of Hesketh Bank, West Lancashire, near to shops, pubs and other village amenities. It has car parking available and has extensive grounds to the front side and rear of the home. There is a patio area and an ornamental fishpond. South View Lodge provides all ground floor accommodation with all but one of the rooms offering single occupancy. Seven rooms have the benefit of an Care Homes for Older People Page 4 of 29 care home 30 Over 65 30 0 Brief description of the care home en-suite. There are three lounge areas throughout the house, one of which has been sub-divided to create small alcoves and a conservatory. There is one main dining area, central to the house. Accessible toilets and bathrooms are located near to bedroom and living rooms. The weekly charges at the home range between £346.00 and £390.00 with additional charges being made for hairdressing, aromatherapy and chiropody. Information about South View Lodge can be obtained from the home in the form of the Statement of Purpose and Service Users Guide. Previous inspection reports can be viewed in the home or on the Commissions website at www.csci.org.uk Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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: A key unannounced inspection, which included a visit to the home, was conducted at South View Lodge on 21st January 2009. The inspection was carried out by one inspector, however, the report refers to we as it was written on behalf of the commission. We lasted visited this service on 24th January 2007 and an annual service review was carried out on 24th January 2008. At the time of the visit there were 24 people accommodated in the home, with an additional two people in hospital. During the inspection we spent time with the residents, looked round the home, read some of the residents care records and other documents and talked to the staff, the responsible individual and the registered manager. We also consulted our records about the service. As part of the inspection Care Homes for Older People Page 6 of 29 process we used case tracking as a means of gathering information. This is a way of inspecting which allows us to focus on a small group of residents living at the home, to assess the quality of the service provided. Prior to the inspection, the responsible individual completed an Annual Quality Assurance Assessment known as AQAA. This is a detailed self assessment questionnaire covering all aspects of the operation and management of the home. This provided us with useful information and evidence for the inspection. Satisfaction questionnaires were sent to the home for distribution to the staff and the residents. Three questionnaires were returned from the staff and one questionnaire was received from a resident. The responses from the questionnaires were collated and used throughout the inspection process. What the care home does well: What has improved since the last inspection? Since the last inspection, the residents photographs had been added to the medication records and all handwritten entries on the administration records had been signed by two members of staff. This meant that staff had checked the prescription details carefully and they were able to easily identify the residents, when administering medication. Consequently this ensured that the potential for error when giving medication had been minimised. A number of improvements had been made to the premises, to aid the comfort of the residents. These included new carpets in the main corridors and many of the bedrooms. Several areas of the home had also been redecorated and the heating system had been completely replaced. The latter improvement meant that the heating system was more efficient and the temperature in the home could be easily monitored. Care Homes for Older People Page 8 of 29 The registered manager had completed the Registered Managers Award. This is meant the manager had the necessary qualifications to enable her to carry out her role effectively. 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 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents had their needs assessed and they were provided with appropriate written information to enable them to make an informed choice about where to live. Evidence: Written information was available for residents in the form of a statement of purpose and service users guide. The service users guide had been issued and explained to all residents and their families and the statement of purpose was available for residents to look at in the entrance of the home. The documents seen were presented in an easy read format and provided useful and informative information about the home. Residents spoken to confirmed they had received a copy of the service user guide, one person said, I looked at it when I moved in, it was very helpful. Copies of the last inspection report were available for reference in the lounge at the entrance. Privately funded residents had been issued with a contract and residents funded by the Care Homes for Older People Page 11 of 29 Evidence: local authority had been provided with a statement of terms and conditions. A copy of the contract was included in the service users guide. The contract was easy to read and was presented in a clear format. This meant that residents were aware of their rights and obligations and knew what they could expect from the service. The case tracking process demonstrated that the residents had their needs assessed prior to admission by a social worker and/or a member of the management team. The pre admission assessment was carried out at a convenient time and place for the prospective resident, to ensure they had the time and opportunity to participate in the assessment process. However, whilst the assessment format covered the potential residents healthcare and medical needs, there was limited information about the residents personal, social and cultural needs. This information is important so the staff are aware of the residents preferred way of life and their individual requirements. Written evidence seen in the residents files demonstrated that residents were not admitted into the home without an assessment of needs. This meant the registered manager could be confident that the staff had the necessary skills and knowledge to meet the assessed needs of prospective residents. The responsible individual said that prospective residents were invited to spend as much time as they wished in the home prior to making the decision to move in. This enabled the person to meet other residents and staff and experience life in the home. Following admission, the contract/statement of terms and conditions stated that a trial period of four weeks was offered to every new resident, so both parties could make sure the placement was successful and the residents individual needs could be met. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care received by residents was based on their individual needs. Care practice took full account of the residents privacy and dignity. Evidence: Three residents files were looked at in detail as part of the case tracking process. All three files contained a care plan, which was based on the residents assessment of needs. The plans were supported by records of personal care, which provided information about changing needs and any recurring difficulties. Entries had been made on a daily basis, to ensure staff were provided with up to date details about the residents well being. The records were detailed and the residents needs were described in respectful and sensitive terms. The care plans covered the residents personal, social and health needs and provided staff with clear guidance on how best to meet these needs. Staff who completed a questionnaire indicated that they were given up to date information about the needs of the residents. Care Homes for Older People Page 13 of 29 Evidence: Written records seen on the residents files demonstrated that the care plans were reviewed each month and updated in line with changing needs. This meant the staff had access to current information about the residents health and well being at all times. The registered manager confirmed that wherever practicable the residents and their relatives were involved in the development and review of their care plan. This ensured the residents had an active role in the planning and delivery of their care. Further to this, the registered manager agreed to ask the residents to sign their care plan to indicate their involvement and participation. Healthcare needs were considered during the assessment process and included within the care plan. This meant that staff were provided with information about how to monitor and respond to specific medical conditions. There was written evidence within the personal care notes to indicate that the residents accessed NHS services and received specialist support as necessary, for instance the District Nursing Team. The registered manager confirmed that charts were maintained to monitor the residents weight, to ensure any fluctuations were noted and acted upon. Detailed risk assessments had been carried out, in respect to moving and handling, pressure sores, falls and nutrition. The risk assessments were supported by risk management strategies, which provided staff with guidance on how to manage and reduce any identified risks. This meant the staff were able to respond consistently and safely to any assessed risks. The risk assessments had been reviewed alongside the care plans, to ensure an holistic view was taken of the residents needs. The residents spoken to felt the staff respected their rights to privacy and dignity and all made complimentary remarks about the staffs approach, for instance one person said, The staff are very good, you only have to have ask and they are there to help. The resident, who completed a questionnaire indicated that they received the care and support they needed. The staff were observed to interact with the residents in a positive manner and they referred to the residents in their preferred form of address. During discussions, staff demonstrated an awareness of treating people with respect and considering their dignity when providing personal care. Policies and procedures were in place to cover the management of medicines and were available for staff reference in the medication file. Since the last inspection, the residents photographs had been added to the medication records and all handwritten entries had been countersigned. The home operated a monitored dosage system of medication, which was dispensed into blister packs by a local Pharmacist. All staff designated to administer medication had received accredited training. However, it was noted that procedures had not always been drawn up to cover the administration of Care Homes for Older People Page 14 of 29 Evidence: medication prescribed as necessary and instructions for the application of prescribed creams had not always been recorded within medication records. It is important for staff to have ready access to this information to ensure all medication is given to the residents in a safe and consistent manner. Care Homes for Older People Page 15 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were able to exercise choice and control over their lives and were supported to maintain good contact with their family and friends. The residents were provided with a nutritious and varied diet. Evidence: The residents preferences in respect of social activities were recorded and considered as part of the care planning processes. A range of activities was planned and implemented by the registered manager and staff. These included nail care, dominoes, karaoke, arts and crafts and aromatherapy. The residents were encouraged and supported to participate in the activities as they wished. Residents spoken to during the inspection had mixed views about the activities, one person said she preferred to rest rather than join in and another person said she enjoyed playing dominoes. The residents were consulted on a daily basis about what activities they wished to pursue. Information about forthcoming activities was displayed in the entrance of the home. On the day of inspection, the residents were observed to be watching television and chatting to staff. The staff on duty explained that the residents would be asked later in the day if they wished to play dominoes or make a jigsaw. Care Homes for Older People Page 16 of 29 Evidence: The residents were supported to continue with their chosen form of religious worship. Representatives from local churches visited the home for prayers and communion and an ecumenical service was held every three months, for all those residents who wished to participate. The registered manager said that it was hoped the frequency of the services would be increased in the future. The daily routines were flexible and were primarily designed to meet the needs of the residents. The residents spoken to said they had a choice in the times they got up and went to bed. The staff were observed to seek the residents views throughout the inspection and the residents spoken to felt comfortable to comment on life in the home. The residents had the opportunity to develop and maintain important personal and family relationships. There were no restrictions placed on visiting times and residents were able to receive their guests in private, should they wish to do so. Refreshments were offered to visitors, to ensure they felt welcome in the home. A relative spoken to during the inspection said she was satisfied with the quality of care. All the residents spoken to said they liked the food provided. There was a choice of food each meal time and residents were asked prior to each meal what choice they wished to make. The food was mostly homemade and breakfast was served throughout the morning to suit the preferences of the residents, who wished to have a lie in. The menu was displayed in the dining room and on a notice board in the entrance of the home. Residents were asked their opinion of the food on an ongoing basis and they could make suggestions for future meals. The meal served on the day of inspection was plentiful and well presented. Residents were given sensitive and appropriate support to eat their meals. Drinks and snacks were served throughout the day and at other times on request. Care Homes for Older People Page 17 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were able to express their views and any concerns and had access to a clear complaints procedure. There were established ways of working to respond effectively to any suspicion or allegation of harmful practice. Evidence: Arrangements were in place to ensure the registered manager and staff listened to and acted on the views and concerns of residents. This was achieved during daily conversation, one to one discussion, residents meetings and satisfaction questionnaires. The residents spoken to said they felt comfortable about expressing their views and were aware of whom to speak to in the event of a concern. Staff who completed a questionnaire also indicated that they were aware of what to do if the residents or their families had a concern. This ensured any problems could be promptly rectified. The complaints procedure was included in the statement of purpose and service users guide and was also displayed in entrance of the home. The residents had been issued a personal copy of the complaints procedure as part of the service users guide. The procedure contained the necessary information and included the relevant telephone numbers and contact details should a resident wish to raise a concern. According to information in the AQAA, the registered manager had not received any Care Homes for Older People Page 18 of 29 Evidence: complaints during the last twelve months. An appropriate recording system was in place in the event of a complaint being made. Policies and procedures for safeguarding vulnerable adults were available and provided guidance for staff should they suspect or witness any harmful practice. However, whilst the procedure recognised the role of Social Services, there was no mention of informing the Commission in the event of an alert. This meant there was the potential for the Commission not being aware of a significant incident in the home affecting the welfare of the residents. Issues relating to the protection of vulnerable adults were incorporated into the staff induction training and staff received specific tuition as part of mandatory and NVQ training. The staff also had access to a whistle blowing procedure. This set out a system for staff to report any concerns about colleagues or managers to the relevant authorities. Care Homes for Older People Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents were provided with a clean, pleasant and well-maintained environment, which promoted their comfort and independence. Evidence: South View Lodge is a mature detached property set in its own grounds in a quiet residential area in the village of Hesketh Bank. The home is located near to local shops and other amenities and close to main bus routes to nearby towns. Accommodation is provided is 28 single rooms and 1 double room, seven of the rooms have an ensuite facility. Communal space is provided in two lounges, one dining room and a conservatory, all of which could be used for a variety of recreational activities. The entrance hall could also be used by residents as a quiet area to sit or entertain their visitors. Bathrooms and toilets are conveniently positioned around the home with the relevant aids and adaptations. The residents had free movement around the home and could choose where they wished to spend their time. Since the last inspection, a number of improvements had been made to the premises, to aid the comfort of the residents. These included new carpets in the main corridors and many of the bedrooms. Several areas of the home had also been redecorated and the heating system had been completely replaced. However, it was noted that it was difficult to gain access to the bathrooms when the door was locked. This is important Care Homes for Older People Page 20 of 29 Evidence: to allow staff entry to the room in the event of an emergency. The responsible individual carried out a quality assurance audit of the environment on a regular basis, to ensure all necessary repairs were carried out and identify any improvements. Arrangements were in place for general maintenance and repairs. This meant that routine problems with the building were promptly rectified. It was evident from a partial tour of the building that the residents had personalised their rooms with their own belongings and decoration was a satisfactory standard throughout. The residents said they liked their bedrooms. One person said, My room is very nice, I like having my own things in it. All the bedroom doors were fitted with appropriate locks and keys had been distributed to those residents who wished to lock their doors. Radiators had been fitted with guards, to minimise the risk of burning if a resident accidentally fell against the radiator. The home was clean and odour free at the time of the inspection. The residents spoken to said that a good level of hygiene was maintained at all times. Care Homes for Older People Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents benefited from experienced, competent and well-trained staff. Evidence: A staff duty roster was drawn up in advance and provided a record of the number of hours worked by the staff in the home. The roster indicated that a sufficient number of care staff were on duty throughout the waking day plus ancillary staff to carry out cooking and domestic duties. Two members of staff were on waking watch duty with an additional person available on call. All staff who provided personal care were aged over 18 and all staff left in charge of the building were aged over 21. Many of the staff had worked at the home for several years which meant they had a good knowledge of the needs of the residents. A recruitment and selection procedure was available for staff reference within the policy and procedure file. The files of two members of staff were looked at in detail. It was evident that both applicants had completed an application form and had attended the home for an interview. However, from the documentation seen there were various shortfalls in the collation of records and checks necessary for the employment of new staff. It is very important that new staff are thoroughly checked before they commence employment in the home, to ensure they are suitable to work with Care Homes for Older People Page 22 of 29 Evidence: vulnerable people. Further to this, the responsible individual immediately updated the recruitment and selection procedure and introduced a detailed checklist to be used to track the required regulatory documentation. Written confirmation was received following the inspection that the new procedure and checklist had been implemented with immediate effect. Arrangements were in place for all new employees to undertake induction training, which incorporated the Skills for Care standards. The latter provided underpinning knowledge for NVQ level 2. According to information supplied by the responsible individual 12 out of 19 care staff had achieved NVQ level 2 or above, which equated to 63 of the overall staff team. In addition six members of staff were working towards this qualification or NVQ level 3. This meant a good majority of the staff team had achieved the necessary qualifications to enable them to carry out their role effectively. All staff who completed a questionnaire confirmed they had received training relevant to their role and all indicated that they were well supported by the management team with any training needs. Staff attended both internal and external training courses and had at least three paid days training a year. There was an overall staff training plan, which meant the registered manager could readily identify any future training needs for individual staff and for the staff team as a whole. Care Homes for Older People Page 23 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management and administration practices were effective in ensuring the home was run in the best interests of the residents. Evidence: The registered manager had overall responsibility for the day to day management of the home and had achieved NVQ level 4 in Care. Since the last inspection, the manager had completed the Registered Managers Award and undertaken various short courses, including health and safety, moving and handling and management of medication to refresh her knowledge and skills. The management approach was consultative and there were established ways of working to consult the staff and residents on an ongoing basis. Relationships within the home were positive and staff spoke to and about the residents with respect. Further to this, a member of staff wrote in a questionnaire, The service treats service users with respect and dignity at all times. Its a very nice place to work and another member of Care Homes for Older People Page 24 of 29 Evidence: staff commented, The service provided enables the service users to keep their identity and individuality. The service was reaccredited with an Investors in People Award in 2008. This is a professionally recognised quality assurance award. Satisfaction questionnaires had been distributed to residents and their relatives in January 2008 and again in January 2009. The results of the questionnaires from January 2008 had been collated and the residents had been provided with feedback about the outcome of the survey. The responsible individual had produced a detailed annual development plan, which set out the objectives for the forthcoming year based on the results of the quality monitoring processes. This document linked with the AQAA questionnaire submitted to the Commission. All sections of the AQAA were completed and the information provided gave a clear picture of the current situation within the service and the planned areas for development. At the time of the inspection, there was no money deposited on the premises by or on behalf of a resident. Computer systems were in place to invoice the privately funded residents. There was a set of health and safety policies and procedures, which included the safe storage of hazardous substances, food safety and infection control. Staff received mandatory health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Documentation seen during the inspection and information supplied in the AQAA indicated the electrical, gas and fire systems were serviced at regular intervals. The fire log demonstrated that the staff had received instructions about the fire procedures during their induction. Arrangements were in place to record accidents and incidents in the home, however, the Commission had not been notified of all significant events in the home. This meant we were not aware of these incidents or how the occurrences were being managed by the responsible individual and registered manager. Care Homes for Older People Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 29 19 All pre employment records and checks must be collated in line with regulatory requirements. This is to ensure the residents are fully protected and staff working in the home are suitable to work with vulnerable adults. 28/01/2009 2 38 37 The Commission must be 28/01/2009 notified without delay of any occurrence listed under Regulation 37. This is so the Commission can monitor events in the home and ensure such incidents are managed appropriately. 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 27 of 29 1 3 The assessment format should cover all elements listed under National Minimum Standard no. 3. This is to ensure that all areas of need are assessed and considered during the admission process. Protocols should be drawn for the administration of all medication prescribed as necessary. This is to ensure that this type of medication is administered consistently and safely. Instructions for the application of prescribed creams should be recorded within the medication records. This is to ensure that staff are aware of how and where to apply the cream. The safeguarding adults procedure should be updated to include the requirement to notify the Commission in the event of a safeguarding alert. This is to ensure the Commission is aware of any such incidents affecting the well being of the residents. The bathrooms should be fitted with privacy locks, which are easily accessible to staff in the event of an emergency. 2 9 3 18 4 21 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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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