Inspection on 04/11/08 for St Catherine`s Manor

This inspection was carried out on 4th November 2008.

CSCI found this care home to be providing an Good 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

St Catherine`s Manor 28/11/06

St Catherine`s Manor 08/11/05

St Catherine`s Manor 23/05/05

St Catherine`s Manor 08/11/04

St Catherine`s Manor 08/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: St Catherine`s Manor Portsmouth Road Artington Guildford Surrey GU3 1LJ     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Suzanne Magnier     Date: 0 4 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: St Catherine`s Manor Portsmouth Road Artington Guildford Surrey GU3 1LJ 01483531181 Telephone number: Fax number: Email address: Provider web address: stcaths@carehomesofdistinction.co.uk Name of registered provider(s): Name of registered manager (if applicable) Louise Jane Kbies Type of registration: Number of places registered: Mr L Hasham care home 34 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 34. 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: Dementia (DE) Old age, not falling within any other category (OP). Date of last inspection Brief description of the care home St Catherines Manor is a large detached house located on the outskirts of Guildford and provides accommodation with nursing care for up to thirty-four Older People some of whom suffer with dementia. The home is set out on two floors and is comfortably furnished in a homely style. Service users bedrooms are tastefully decorated, and contain many personal items. Several have en-suite facilities. There is a large garden Care Homes for Older People Page 4 of 30 Over 65 0 34 34 0 Brief description of the care home with shrubs, hedges, and flowers. Car parking facilities are available at the front of the house and public transport is readily available. A mini bus is available for service users outings. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The Quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. The Commission for Social Care Inspection, (CSCI) has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the care home was an unannounced Key Inspection. Ms S Magnier Regulation Inspector carried out the inspection and the registered manager and general manager represented the service. For the purpose of the report the individuals using the service are referred to as residents. The inspector arrived at the service at 08.00 and was in the home for eight hours. It Care Homes for Older People Page 6 of 30 was a thorough look at how well the service was meeting the key National Minimum Standards for Care Homes for Older People and has in this report made judgements about the standard of the service. The CSCI Inspecting for Better Lives (IBL) involves an Annual Quality Assurance Assessment (AQAA) to be completed by the service, which includes information from a variety of sources. This document was received by CSCI prior to the inspection and written comments received from residents, staff and people associated with the home have been included within the report. The information contained in this report was gathered from observation by the inspector and speaking with a number of residents and care staff. A full tour of the premises was undertaken and documents sampled during the inspection included some residents care plans, daily records and risk assessments, medication procedures, health and safety records, staff training and recruitment records, some of the homes policies and procedures, quality assurance records and some finnancial records. The final part of the inspection was spent giving feedback to the service representatives about the findings of the visit. The commission had received information regarding one safeguarding vulnerable adult referral which had been well managed by the home. From the evidence seen by the inspector it is considered that the home would be able to provide a service to meet the needs of residents who have diverse religious, racial or cultural needs. What the care home does well: What has improved since the last inspection? What they could do better: It has been required that the Statement of Purpose and the Service User Guide be updated in order that prospective residents and their representaives have up to date information about the services and facilities provided by the care home in order that they can make an informed choice about residing at the home. Arrangements regarding the control of infection in the home must be strengthenned. Care Homes for Older People Page 8 of 30 Residents must be able to summon assistance when necessary and equipment to assist them must be at hand. 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 adequate 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 representatives do not have up to date information regarding the services and facilities offered by the home in order that they can make an informed choice about residing at the home. The admission and assessment procedures ensure that prospective residents needs are appropriately identified prior to moving into the home. The home does not provide intermediate care. Evidence: The Statement of Purpose provided during the inspection was not a final completed document and the Service User Guide was dated 2004. The registered manager advised that the documents were in the process of being sent to the local Head Office to be reprinted. It has been required that the Statement of Purpose and Service User Guide be updated in order to ensure that prospective residents and or their representatives have up to date information about the registered care home. Care Homes for Older People Page 11 of 30 Evidence: Four care plans were sampled and contained documents which evidenced that the homes qualified staff undertake a full assessemnt of an individuals medical, personal, social and emotional needs prior to the individual residing at the home in order to ensure that the staff can meet the individuals needs. Written comments received by the commission about the support received during the intial contact and viewing of the home included they have been so understanding on all matters medical and general, I visited St Catherines and they spent a long time showing me around and answering questions. I was given a conducted tour of the home and I found it to be satisfactory. We were very happy with the information we received and the attention devoted to us. 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. Individuals care plans were up to date and individuals health care needs were met. A person centred approach to care is being implemented by the home which will benefit and promote more individualised care. Consultation with individuals about their care needs needs to be strenghtened. Medication procedures are robust. The monitoring of risk assessments has been maintained to ensure the safety of people in the home. Arrangements to promote residents rights to dignity, privacy and respect and for residents to summon assistance within the home must be improved to ensure their safety and welfare at all times. Evidence: Four residents care plans were sampled and each contained information and evidence to confirm that the individuals care plans had been developed from the pre assessment documentation and information received from other healthcare professionals. The registered manager explained that there were several systems in place regarding care plans and that the homes staff were currently transferring residents care plans to Care Homes for Older People Page 13 of 30 Evidence: a new system, which was designed to be more person centred and support the resident in a more holistic way. Several person centred plans that had been partially completed were well recorded and gave the reader an understanding of the individual in addition to their medical and personal care needs. From the information gathered and by observation and talking with staff during the inspection it was concluded that the care and support given to residents was reflected within the individuals care plan with regard to their health social and emotional needs. Documented risk assessments were available in residents care plans and included hazards identified such as mobility, nutrition, use of bed rails, management of pain, bathing, cross infection, falls, personal hygiene and bathing. The care plans documented any recognised concerns regarding tissue viability and care of residents pressure areas. Information regarding support from other healthcare professionals included speech and language therapists, occupational therapists, visits by district nurses and physio therapists was also available within the care plan documents. It was observed that staff were vigilant to residents who required turning whilst in bed and support with fluids and documentation was available to record when individuals received this support. Written comments received by the commission about the healthcare provided by the home included I have met the doctor on several occassions, and I am 100 per cent confident in the medical treatment and support my relative receives and I am fully notified of any changes. During the inspection it was observed that several residents who were in their bedrooms, either in their armchairs or in bed did not have their call bells available to them. One resident told the inspector that they had to get out of the chair in order to ring the bell and that they had talked to staff about how difficult they found it. The shortfall was brought to the operations and registered managers attention during the inspection. It has been required that each resident must have access to a bell or similar equipment in order that they can summon assistance when needed in order to promote their safety and well being. It was noted that not all of the care plans sampled had been signed by the resident or their representative and one care plan had not been signed by the staff member completing the plan. It is required that residents or their representatives are consulted regarding the formation of the care plans and arrangements must be made that the new care plans are signed by the resident or their representative to ensure that the care and support provided by the homes staff is agreed. The home have achieved some balance between nursing and a residential setting and this was discussed with the manager during the inspection and with the promotion of a more holistic approach to the care of residents this ethos will be further promoted for the benefit of the residents. Care Homes for Older People Page 14 of 30 Evidence: As previously documented there was evidence to support that appropriate health care appointments including visits by the General Practitioner had been attended and through sampling care plans and observation it was evident that the home maintains good working partnerships with health care professionals which include visits from the opticians continence advisors, dentists and chiropodists to ensure that residents health care needs continue to be met. It was brought to the registered managers attention that a health care professionals guidelines of support for a resident were stuck on the individuals bedroom wall and it was suggested that an alternative method be considered in order that the individuals right to privacy be promoted. Each care plan contained daily records which were professionally written and informed the reader of the twenty four hour period in the life of the individual and were signed by the staff member. The home has a medication policy and procedure in place and has been supplied with a monitored dosage system. The inspector observed that the home has good clear procedures in place for the monitoring and recording of all medicines administered and those entering and leaving the home. Records of controlled medication were not sampled on this occassion yet the inspector was assured by the registered nurse that checks were accurate. Some medication administration charts were seen which were well documented, some contained the residents photograph and were clear to ensure that residents received their prescribed medicines. It was confirmed that only registered general nurses administer medications in the home. It was observed that there were sufficient staff on duty to support residents and in general staff were able to demonstrate a knowledge and understanding of the residents welfare and support needs. Throughout the day the inspector observed that residents were generally addressed in a polite and courteous way by staff however concern was raised by the way in which one frail resident who was being supported from their room in a wheelchair and this was brought to the managers attention at the time of the inspection. The hairdressing arrangements observed during the inspection were also brought to the managers attention and the inspector was assurred that the current arrangements were under review in order that the hairdressing activity is more individualised and person centred. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to make choices about their daily routines and enjoy and choose from a range of activities offered by the home. Visitors are welcomed to the home to maintian contact with their freinds and family. The home provides a healthy and balanced diet in pleasant and spacious dining areas. Evidence: The registered manager confirmed that the home has a dedicated activities organiser who was not available on the day of inspection. A daily activities plan which was available in the dining room was sampled with resident meeting notes which indicated that residents, where able, are given the choice and opportunity to decide what they would like to do and participate in. Some activities included music appreciation, model making, aromatherapy, art and a recent visit to Bird World and entertainment by the Morris dancers. Meetings are also held for residents relatives and friends and the homes atmosphere of welcoming visitors to the house was observed to be positive and reassuring. The home offers details of an advocacy service when initial contact is made by an individual to the home in order that they or their representatives are supported. Staff told the Care Homes for Older People Page 16 of 30 Evidence: inspector that the home supports a local charity with fundraising and the residents really enjoy outside speakers coming to the home and being involved in their local community. With the develpoment of the plans it was evident that staff had taken time to find out about the social care needs of individuals and peoples past occupation, hobbies, interests and skills had been recorded. Some residents were seen to move freely around the home and were relaxed and appeared content. One staff member advised that a member of the Christian clergy visit the home and support residents spiritual and religious needs however as previously documented this is not consistent with residents from diverse backgrounds. There was evidence to support that the home is visited by a hairdresser and several residents said they enjoyed having thier hair dressed as it made them feel better. The home is planning to have a separate hairdressing room, which will be equipped to offer comfort and safety to residents. The midday meal served at lunch time was well presented with each resident being able to sit up to a dining table if they chose to to have their meal and residents stated that the food was generally good. Residents who were not able to support themselves with meals had meals in their bedrooms with support from staff. All residents looked well groomed and protective clothing and napkins were provided at the meal time. A planned menu was displayed in the home to assist residents to make choice about which meal they would like. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes complaints procedure is an accurate document for individuals to express any concerns or complaints. Individuals are protected from abuse and harm by the homes policies and procedures Evidence: The home has a clear complaints policy and procedure and is available within the home to residents or any person associated to the home so that their views, opinions and complaints are recognised and acted upon. The completed AQAA and registered manager confirmed that no complaints have been received by the home and no complainant has contacted the commission with information concerning a complaint made to the service since the last inspection. The registered manager demonstrated that she was aware of the local authoritys multi agency procedures for safeguarding adults and confirmed there had been one safeguarding referral which was being satifactorily monitored. The home has a whistle blowing policy and procedure, which is available to staff in order to safeguard individuals in their care. The home have the current multi agnecy safeguarding protocols dated 2008. Records confirmed that all staff except had received safeguarding vulnerable adults Care Homes for Older People Page 18 of 30 Evidence: training and thr homes staff were procative in encoraging residents rights to an advocacy service. Written comments received by the commission about the homes response to concerns or complaints included The manager is always available to discuss anything and sorts things out quickly. If she is not available the duty manager or head nurse do exactly the same. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well maintained. The control of the spread of infection in the home needs to be strengtenned. Evidence: During the tour of the premises it was observed that the home is well maintained and records of work undertaken by the handy person were sampled and evidenced that a maintenance plan ensures the upkeep of the homes environment for the safety and well being of the residents. The laundry area in the basement of the home was in need of attention and included the laundry door left propped open which was observed as a potential fire hazard, there was a lack of lids on the waste bins and the laundry area was cluttered and untidy. The shortfalls were addressed with the manager who took immediate action to rectify the concerns and commenced a written risk assessment during the inspection. New bins were purchaesd and the manager advised that all staff would be informed of the need to keep the laundry area clean and orderley. Staff were observed wearing protective clothing, including aprons and gloves and hand washing facilities were available throughout the home. Where soap dispensers had not been replenished they were filled promptly by staff during the inspection. It was Care Homes for Older People Page 20 of 30 Evidence: observed that a soiled uncovered commode pan had been left in the sluice room which caused a malodour within the room, and a staff member was observed walking along a corridor with soiled linen and when questionned apperaed unsure about the homes policy and procedures regarding the control of infection. It has been required that more robust arrangements are made with regard to the control of infection in the home in order to promote residents health and welfare. Written comments recieved by the commission about the homes environment stated The home is always fresh but it is looking a bit tired and could do with some painting and decorating. The residents are kept clean and there are no nasty smells. 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. Staff in the home are in sufficient numbers to support the people who use the service. The home has a robust sysytem for induction and training development to ensure residents needs are appropraietly met. Safe vetting of staff and management of recruitment practices are robust in order to protect the welfare and safety of residents. Evidence: Written comments received by the commission about the staff included they are always happy to help and sort things out. Nothing is too much trouble and they come up with good ideas. The staff from the manager down are fantastic and I cannot praise them highly enough, they are so caring to the residents and family and friends. Due to hoildays staff are not trained and due to language problems contact with staff can be difficult. Staffing levels at the home during the inspection were observed to meet the current needs of the residents and staff were at hand promptly to support residents who required assistance. Visitors to the home spoke highly of the manager and staff and how friendly and welcoming the home was. It was observed that the home employs a multi-cultural workforce and equality and diversity issues are addressed within the homes policies and procedures and induction Care Homes for Older People Page 22 of 30 Evidence: programme. The organisation supports overseas staff to undertake English lessons in order to ensure that they are supported to feel more confidant in communicating with residents and their work colleagues. The organistaion has a recruitment and selection policy and procedure. Three staff recruitment files were sampled and evidenced that the homes management generally undertakes safe vetting practices concerning the recruitment of staff. Within one file there was no photo of the staff member despite the staff member being on their first day of induction to the home and the manager was reminded that safe vetting practices concerning the recruitment of all staff to the home must be maintained in order to ensure the safety and protection of residents in the home. The manager advised that the home is committed to the ongoing training and development of staff. Three staff have achieved their National Vocational Qualification (NVQ) Level 2 and one staff has completed Level 3 . Six of the care staff are qualified nurses in their country of origin with other staff undertaking their NVQ training. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is robust to ensure the safety and wellbeing of residents. Residents are consulted regarding the running of the home and their health and financial interests are safeguarded. The health and safety of all persons in the home is promoted and robust policies and procedures are in place. Evidence: During the inspection it was observed that the managers management style was open and approachable and she acknowledged that all peoples views and opinions associated with the service should be listened to and acted upon where appropriate. Visitors were seen to be warmly welcomed to the home and written comments about the homes manager and staff included There were clear lines of management accountability during the day of the inspection and staff, including the nurse in charge, demonstrated an understanding of their roles and responsibilities. All persons spoken with during the inspection spoke highly of the abilities and knowlegde of the manager and her open approach and the staff morale was good. Care Homes for Older People Page 24 of 30 Evidence: Written comments received by the commission about the management of the home included the manager is fantastic in looking after my realtive and always has time to talk to me and makes sure I am OK. She motivates the staff and it is a very happy home and everyone smiles and seem genuinely happy. There is a great sense of humour which everyone enjoys. I visit each day and I am happy with what I see. Sometimes the washing is returned to the wrong room resulting in clothes being mislaid. On one occassion I was given a dress and knickers . I am male. The manager is very caring and responsive and the staff all adopt a positive attitude. The inspector was informed that the Regulation 26 visits take place and any shortfalls in the quality of the service would be noted by the organisation during the Regulation 26 visits, so that appropriate action could have been taken to rectify the shortfalls. This information was confirmed by sampling records and speaking with the Area Manager who was present at the inspection. Some residents financial records were sampled and these were well recorded and clear in evidencing that appropriate safekeeping and regular auditing of the accounts was undertaken in order to safeguard residents from financial abuse. The policies and procedures of the home and organisation were sound and staff demonstrated that they were aware of the core policies and procedures of the home, which included the health and safety policy to ensure that the welfare and safety of all persons in the home is promoted. Records indicated that health and safety checks are maintained, fire safety equipment and records were documented and equipment serviced. The sluice areas were noted to be clean and tidy. The home have maintained records relating to water and food temperature checks to ensure residents safety and well being. The home has the required gas safety and electrical certificates available in the home and a current insurance indemnity certificate was displayed. Accident and incident records were sampled and the inspector re affirmed the procedures that the home must report any incidences to the CSCI under Regulation 37 notifications of any event that affects the well being and welfare of residents in the home. Chemical substances which are hazardous were observed to be be stored in compliance with the control of substances hazardous to health (COSHH)legislation in Care Homes for Older People Page 25 of 30 Evidence: order to ensure the safety and welfare of residents and the homes fridge, freezer and pantry were well stocked. There was written evidence to support that resident views and opinions of the home are actively sought through residents meetings and Quality Assurance documents were made available during the inspection. RecordS of compliments were sampled which indicated that residents representatives were satisfied and happy with the care, including end of life care, provided by the home. 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 1 4 The Statement of Purpose and Service User Guide must be updated to include all the information in the amended Care Homes Regulations. In order to ensure that prospective residents and their representatives have sufficient and appropriate information about the facilities and services offered by the home. 03/03/2009 2 7 14 Arrangements must be made that residents or their representatives are consulted regarding the formation of the care plans. To ensure that the care and support provided by the homes staff is agreed by the resident or their representative. 03/03/2009 Care Homes for Older People Page 28 of 30 3 8 6 Arrangements must be 03/03/2009 made that each resident has access to a bell or similar equipment. In order to ensure that they can summon assistance to promote their safety and well being. Arrangements must be made to ensure that unnecessary risks with regard to the procedures of control of infection in the home are improved. To ensure the wellbeing and welfare of residents. 03/03/2009 4 26 13 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 29 of 30 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!