Inspection on 09/03/09 for St Benet`s Court

This inspection was carried out on 9th March 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Benet`s Court 13/12/07

St Benet`s Court 01/03/07

St Benet`s Court 28/06/06

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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: St Benet`s Court 32 College Road Newton Abbot Devon TQ12 1EQ     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: Wendy Baines     Date: 0 9 0 3 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.cqc.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: St Benet`s Court 32 College Road Newton Abbot Devon TQ12 1EQ 01626354069 01626354069 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Ms Michelle Ann Stepney,Mr Guy Perring Rogers,Mrs Nicola Jayne Rogers Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 40 Number of places (if applicable): Under 65 Over 65 40 old age, not falling within any other category Additional conditions: 0 The maximum number of service users who can be accommodated is 40 The registered person may provide the following category of service only: Care home with nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (Code OP) Date of last inspection Brief description of the care home St Benets, is a large Victorian house situated on the southern slopes of Wolborough Hill Newton Abbot. It overlooks the attractive Decoy Woodland and nature reserve. The home is within a short drive from the town centre and local amenities including British Rail mainline station and direct access to the A38. St Benets offers en-suite facilities in the majority of the single and shared rooms. Residents are assisted moving around the home by the two passenger lifts, one stair lift, grab rails and ramps which offer Care Homes for Older People Page 4 of 30 Brief description of the care home freedom of movement for disabled Service Users. A nurse call system covers all rooms and the gardens. There are well maintained terraced gardens with secluded seating areas and a waterfall accessible to service users. The garden has views over the Devon countryside. The home caters for physically disabled Service Users and has a registered nurse on duty at all times, a range of equipment is available to help meet Service Users needs. Copies of previous inspection reports are available at the home to visitors and those who reside there. 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 Two Star. This means that the people who use this service experience a good quality service. This was an unannounced inspection. It took place over one full day on the 9th March 2009. Prior to the inspection the home sent us a Annual Quality Assurance assessment (AQAA), which told us alot about the home and the people who use the service. It also gave us information about any changes that had taken place in the home or to the way that services are provided since the last key inspection. Care Homes for Older People Page 6 of 30 We also sent out surveys to residents and staff asking them about their views on the service and the care they receive or provide. The inspection comprised of a tour of the premises and examination of records kept at the home, such as care plans, risk assessments and health and safety records. There was also discussion with staff on duty, the Registered Providers, senior staff and visitors. The Inspector was able to spend time talking with the people who use the service and observing staff as they provided care and support. What the care home does well: What has improved since the last inspection? Since the last inspection the Provider has appointed a Registered Manager who is responsible for the day-to day running of the home. As part of the admissions procedure the home has developed a feedback form for new residents and their relatives. The purpose of this is to be able to address any issues promptly and to ensure that people have a positive experience when they move into the home. The home has reviewed systems for recording information relating to peoples health care and nursing needs. This is now recorded and stored separately so that this information is monitored and reviewed by qualified nursing staff. The standard of vetting of new staff has improved. The home now ensures that they have received all Criminal records Bureau checks before a new member of staff starts work in the home. All radiators in the home are now covered to ensure that people are protected from the risk of burns. Care Homes for Older People Page 8 of 30 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.cqc.org.uk. You can get printed copies from enquiries@cqc.org.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. Prospective residents and their families can be confident that they will be given good information to help them make an informed choice about this home. The homes admission procedures ensure that peoples needs are fully assessed and known before they move in. Evidence: The home has information to give people who may wish to use the service such as a Statement of Purpose and Service user Guide. These provide information about the homes aims and objectives, the services provided, the environment and contact details. This information is given to people prior to admission and is also available within the main reception area. The files of four people recently admitted to the home were examined and found to Care Homes for Older People Page 11 of 30 Evidence: provide a clear description of each persons needs and how they would be met at St Benets. The manager said that when initial referrals are made to the home she would carry out an assessment of need with the person who will be receiving the service, relatives if appropriate and other professionals involved in the persons care. Whenever possible arrangements would be made for the person to visit the home. At the time of the inspection one room was being used as a short term respite care facility. Records and discussion with the manager confirmed that a full admissions procedure would be followed for residents who may request to use this facility for a short break. Information provided by the home prior to the inspection stated that as part of the homes Quality Assurance process feedback is gathered about peoples experiences when they move in. The purpose of this is to ensure that any issues can be promptly addressed and the home can continue to improve the service wherever possible. 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. Since the last key inspection improvements have been made in the way the home records the social and health care needs of residents. However, following reviews care plans are not updated in a way that can be easily understood by those providing care and this could lead to errors and inconsistency in the way care is delivered. People living in the home are protected by the homes medication procedures. People who live in the can be confident that their rights and dignity are promoted. Evidence: The Inspector had access to all records relating to the care needs of people living in the home. The care plans of seven people were looked at in more detail, and in some cases the Inspector was able to meet the resident and ask them about their experience of living at St Benets. Feedback from one resident included The staff listen to and act on what I say, they tell me that I have the right to make decisions. Care Homes for Older People Page 13 of 30 Evidence: Since the last key Inspection the home has introduced a new system for recording information relating to peoples health care and Nursing needs. Each persons details are documented and stored in a separate health file and are reviewed by the Nursing staff alongside the other care plan for the home. The health plan included assessment of risk in relation to Falls, malnutrition, skin care and Moving and Handling. These plans detailed the support, staffing and where necessary equipment required to minimize the risk, whilst promoting independence where possible. In addition to the health plan a further care plan is completed covering all other areas of care. The format the home uses allows staff to gather and record information about peoples history, communication, and preferred daily routines. In some cases these records had not been completed and the information contained within these care plans was minimal. Records confirmed that the home undertakes a monthly review of the care needs of each person living in the home. The outcome of reviews are documented on a separate review sheet. If there are to be changes to be made to the persons current plan of care these are hand written onto the original plan. One of the care plans seen had changes made in writing, however the date of the change did not coincide with the date at the top of the plan. Due to lack of space on the form the information had been squeezed in and was difficult to read. This system of care planning does not allow the reader to easily track or understand the current care needs of the person concerned and could lead to errors and inconsistency in the care being delivered. All residents are registered with a local GP and are able to see visiting health professionals in the privacy of their own room. Clear systems are in place for residents who need to have their food and fluid intake monitored. Examples of these were seen and monitoring charts were found to be up to date. The homes systems for administration of medications were examined. As the home is Registered to support people who have been assessed as having Nursing needs the home has a number of Qualified nursing staff who are responsible for this area of care. The homes office has a good amount of space to ensure that medication and records can be safely stored. There are two drugs trolleys available, and these are organised in a way that allows nursing staff to administer medication in two parts of the home. Systems are in place for the appropriate storage and recording of any controlled drugs. Records of the administration of medication was sampled, these were found to be in good order and up to date. The home has a separate fridge for medication that requires low temperature storage. The senior nurse on duty during the inspection said that the homes GP visits on a weekly basis to discuss any particular issues relating to specific health care needs of residents. Care Homes for Older People Page 14 of 30 Evidence: Throughout the inspection staff were observed knocking on residents bedrooms before entering and speaking to residents in a respectful manner at all times. Feedback within one questionnaire completed by a resident included Staff show extreme kindness and respect when supporting me. In discussion staff gave good examples of how they ensured that the privacy and dignity of residents was respected. These examples included ensuring that screens were used in double rooms, people being dressed according to their wishes and recognising peoples preferred choice of routine when being supported with their care. Although people are asked when they move into the home if they would like a lock fitted on their bedroom doors not all rooms have this facility. A lock is not available on the bedroom door used for respite. A lock should be fitted to all bedroom doors so that people are able to make the decision at any time to lock their room for privacy and/or to protect their personal belongings. 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 who live at St Benets have the opportunity if they choose to partake in a range of activities. They can have visitors whenever they wish and are able to enjoy a well balanced diet, which takes into account their likes and dislikes. Evidence: The Inspector was able to discuss daily life and social activities with staff, residents and visitors. It was also possible to observe how people were spending their time and the interaction between staff and the people they were supporting. The manager said that when people are admitted to the home information is gathered about their interests, daily routines and important people in their lives. An activities coordinator is employed by the home and works closely with staff and residents to plan activities and to gather regular feedback on the outcome of these events. Information about local events and in-house activities were available on the homes notice board and a weekly activities plan included activities such as Bingo, gentle exercise , poetry and reminiscence groups. Minutes from a recent residents meeting were also displayed on the notice board and confirmed that residents are asked to give Care Homes for Older People Page 16 of 30 Evidence: feedback about the activities and services provided. Visiting Clergy enable residents of different denominations to practice their chosen religion. Throughout the visit the atmosphere in the home was warm and welcoming. Several residents were sat in the main sitting room relaxing or watching television. One resident had been provided with a book stand to assist with reading and said that a mobile library also visits the home providing large print and audio assisted books. During the afternoon of the inspection visit several residents joined in a games afternoon arranged by the staff. Throughout the duration of the inspection visitors were seen coming and going. One relative spoken to said she visits on a daily basis and is always made to feel very welcome by the staff. Information on the homes notice board advices family that they are more than welcome to join their relative for a meal, and to inform the chef if this is required. Visitors also said that they are always offered drinks and cakes during their visit to the home. The Inspector was able to see the daily menu, speak with kitchen staff and observe the support offered to residents during the lunchtime meal. During the busy lunchtime the kitchen was well organized. The chef had details of each residents likes,dislikes and any special dietary requirements. He said that this information was regularly updated. Residents are offered hot and cold drinks throughout the day and are informed each morning about the menu for the day and their choice of meal recorded. The homes dining room is small and this created quite a busy atmosphere due to the number of residents and staff offering support. The manager said that the home was aware of this situation and were considering the space required to improve meal times as part of the long term plans for the home. Despite the size of the room residents were clearly enjoying their meal and the opportunity for friendly discussion with staff and other residents. The meals provided were of a good standard and the tables were attractively laid with tablecloths and fresh flowers. Twenty residents completed surveys requested by the Commission prior to the inspection. Half of surveys returned stated that the residents always enjoyed the food and the other half said that they usually enjoy meals. One resident said that the food is always well presented with plenty of fresh vegetables and fruit. 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. People who live at St Benets can feel confident that their concerns and complaints will be listened to and taken seriously. The Registered Manager and staff are effective in protecting people from abuse. Evidence: St Benets has a written complaints procedure. This informs residents, their families and any person with an interest in the service about how they can make a complaint and how they should expect this to be dealt with by the home. Minutes from a recent residents meeting confirmed that people are reminded about this process and about who they can speak to if they want to raise any concerns. Discussion with people who live in the home and feedback within questionnaires confirmed that people know how to make a complaint and feel confident that any issues they raise will be taken seriously by management and staff. Since the last Key Inspection the Commission has received one complaint regarding the service. The information was passed to the manager who undertook an investigation of the issues raised using the homes complaints procedure. The home sent a report of the outcome of their investigation to the Commission and the complainant. Although the complaint was found to be unsubstantiated the manager did advise the Commission that they had reviewed areas of their practice as a result of the information received. This Care Homes for Older People Page 18 of 30 Evidence: demonstrates that the home takes any complaints seriously and uses this information positively to further improve the service. Records showed that staff receive training regarding the protection of vulnerable adults and those spoken to were able to demonstrate a good understanding of the procedures to follow should they believe a resident is at risk of abuse. A flow chart of these procedures were also available within the staff office. Inspection of staff records showed that the homes recruitment procedures are robust and sufficient checks are carried out to ensure that any new staff member is suitable to work with and support vulnerable people. 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. The standard of the environment within this home is good providing people with an attractive, clean and safe place to live. The homes on-going maintenance and improvement plan for the environment ensures that good standards are maintained and any issues are promptly addressed. Evidence: As part of the Inspection a tour of the premises was carried out. St Benets is situated in a residential area of Newton Abbot. It is a detached, older style property situated in grounds shared by another home by the same proprietors. Information received by the provider prior to the visit confirmed that maintenance and refurbishment of the home is on-going. Examples of this were the fitting of new carpets throughout the home, a new television in one of the communal sitting rooms, new chairs in both lounges and replacement of some nursing beds. The manager also said that there are plans to refurbish the kitchen and relocate the office to a more suitable part of the home during the next year. There is an attractive entrance area with seating for visitors, a signing in book and notice boards displaying information about the home and services available. Care Homes for Older People Page 20 of 30 Evidence: Residents have the use of two communal sitting rooms. During the visit one of these rooms was being used by residents for an afternoon group activity, whilst some residents chose to use the other room to relax and watch television. All areas of the home are accessible to those who live there, through either the use of the two passenger lifts or by the use of the stairs. There is also a chair lift available on the main staircase. Several bedrooms were seen during the visit. All were found to be nicely decorated with lots of residents personal belongings, which made the environment feel more homely. Bedrooms were bright, warm, clean and tidy. All bedrooms had a call system and residents spoken to were very used to using this facility. The manager said that on admission to the home people are asked if they require a lock on their bedroom door and that this is provided when requested. Some of the bedrooms did not have locks fitted. The manager said that all radiators in the home have now been covered to ensure that people are protected from the risk of burns. The kitchen was found to be clean, tidy and very well organized. This was divided into two areas to allow staff to prepare drinks and snacks, whilst allowing the chef space to cook the main meals for the day. The laundry area comprised of two sections. One within the main building where ironing and sorting of clothes takes place, the other in structures external to the main building where domestic washing machines were situated on an impermeable floor in rooms with easily washable floors. There is a staff room located in the basement of the home and this is accessed via a steep flight of stairs leading from the main hallway. The manager said that the door leading to the stairs is always kept locked to ensure the safety of residents. Externally the home has pleasant and well maintained garden areas, complete with a water feature and lovely views of the surrounding countryside. The gardens are easily accessible to those who live in the home. All of the residents who completed questionnaires confirmed that the home is always kept fresh and clean. Care Homes for Older People Page 21 of 30 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. People who live at St Benets will receive care and support from a skilled group of staff who will be sufficient in number to meet their current and changing needs. Since the last inspection the standard of vetting and recruitment has improved further ensuring that people who use the service are safeguarded. Evidence: Staff were described by people living in the home and those visiting as very respectful and kind, and always being available to help. People said that they were supported promptly indicating that staff were employed in sufficient numbers to meet the needs of those currently living in the home. This was also supported by observation of staffing levels during the visit and inspection of the homes staffing rota. In addition to care and nursing staff the home also employs a chef, kitchen assistant, two cleaners, laundry staff and a activities coordinator. Staff who completed questionnaires said that there are usually enough staff on duty other than times which cannot always be planned for such as staff sickness. Throughout the inspection staff were attending to chores, assisting residents and spending time with residents in the communal parts of the home. Staff were seen Care Homes for Older People Page 23 of 30 Evidence: chatting and laughing with residents and organized activities took place in the communal lounge during the afternoon. Staff spoken to had a good understanding of the needs of residents and said that more recently the information available to them about residents had improved and was more accessible and easier to understand. As the home is Registered to provide nursing care there is always a Registered nurse on duty. All nursing staff in the home receive support and advise from a clinical lead for nursing care. The manager said that the home also works closely with the local GP practice and other health care professionals. The personal files for three recently appointed staff were looked at during the inspection. All these files contained a detailed application form, interview notes, two written references and a Criminal records disclosure. The manager said that staff are not able to start work without these checks having been completed. Each of the staff files had a check list at the front with the dates that this information had been requested and received. New staff were provided with Induction training to ensure they are given information about the care home and the people living there. This was evidenced in a number of staff files. One member of staff who had been more recently appointed said that the induction allowed her to read all the care plans, policies and procedures and watch a video relating to the protection of vulnerable adults. She said that during this time she shadowed a member of the staff team and was involved in admitting a new resident to the home. Staff files and training records confirmed that staff complete and update training in health and safety, fire safety, moving and handling, food hygiene and first aid. The manager confirmed that nearly all staff either had or were in training for a National Vocational Qualification, a nationally recognized qualification for which staff must demonstrate their knowledge and skills in supporting older people. All staff have access to the Registered providers rolling training programme and information about training opportunities were detailed on the notice board within the staff office. Staff spoken to said that they are always supported and encouraged to update their training. 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 home benefits from an open, inclusive and positive style of management. The manager is supported well by the senior and nursing staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which include seeking the views of residents, staff and relatives. Evidence: Since the last inspection the Registered Provider for St Benets has appointed a Registered Manager to take on day to day responsibility for the home. Mrs Patricia Gleave was Registered by The Commission for Social Care inspection on the 11th February 2009. Mrs Gleave had previously worked in three other homes owned by the Care Homes for Older People Page 25 of 30 Evidence: organization and was the appointed manager within two of these services. Prior to the appointment of Registered manager she has worked within a senior position at St Benets since 2007. Mrs Gleave does not have a nursing qualification but is assisted within her role by a clinical lead for Nursing care and other senior staff within the organization. She has an NVQ qualification in care and undertakes regular training relating to general nursing care and other areas relevant to the needs of the people they support. In addition Mrs Gleave is also in the process of undertaking a management award in Leadership and Care. Systems are in place to promote and improve the quality of the service. A monthly audit is completed, which covers all aspects of the day to day running of the home, including admissions, records, environment and care. Questionnaires are sent out to residents and their relatives for feedback on the quality of the services provided. This information is evaluated and used as part of the homes annual improvement plan. The home also sends out questionnaires to family following an admission of a relative. The manager said that the aim of this is to address any issues for new residents as quickly as possible. Comments from questionnaires sent out in January 2009 were available on the homes notice board and included; I am impressed by the care and dignity shown to residents, Staff are always kind and friendly, All the information I needed was passed to me by the manager. Whilst the providers encourage those who live at the home to manage their own finances or let their relatives oversee or take responsibility for this there are occasions where the home has to hold monies on their behalf. Where this occurs, the monies were seen to be kept securely with records kept of all transactions made on behalf of the resident. The manager said that a weekly audit is completed of all residents finances and records. The inspector was able to observe a staff handover meeting led by the lead nurse. Staff who had come on duty were informed of what had happened during the day and advised of any important issues concerning residents. Staff records confirmed that formal 1:1 supervision sessions take place on a regular basis. Staff spoken to said that these meetings gave them the opportunity to discuss their role within the home, any particular concerns they may have and their training needs. These meetings were documented. The manager said that staff are also given a supervision form between formal meetings to document any issues and these can be passed to the manager at any time. All the staff gave very positive feedback about the support provided to them by the Registered Manager. One staff member said that they are kept fully informed of any important issues and feels that staff views are valued and taken seriously. Care Homes for Older People Page 26 of 30 Evidence: A sample of the homes records were inspected including care records, risk assessments, staff files and health and safety information. The manager was able to demonstrate where improvements had taken place particularly in the area of care planning and risk assessment. It was noted that as care plans are hand written it was in some cases difficult to track changes made to the care plan following a review and whether or not the current care plan was up to date. This area of concern was discussed with the Registered Manager and the owner of the home. Health and safety records were examined. Records of training reflected staff access to the Registered Providers training programme in Health and Safety. This included topics such as infection control, moving and handling and first aid. Information provided prior to the visit confirmed that there are up to date maintenance and servicing of systems and equipment. Risk assessments for the building and fire safety were available for inspection. Records confirmed that a record is kept of any accidents or injuries to residents and appropriate agencies are informed of these events. 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 7 15 The process for updating 20/06/2009 care plans following a review or change in need must be reviewed. Any changes made to an individuals care plan must be clear to those providing care to prevent any errors and to ensure consistency. 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 10 A suitable locking facility should be available on all bedroom doors to ensure that residents are able to make the decision to lock their door at any time. Care Homes for Older People Page 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.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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