Inspection on 29/10/08 for St Joseph`s Rest Home

This inspection was carried out on 29th October 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

St Joseph`s Rest Home 12/10/06

St Joseph`s Rest Home 07/11/05

St Joseph`s Rest Home 23/05/05

St Joseph`s Rest Home 06/09/04

St Joseph`s Rest Home 10/05/04

St Joseph`s Rest Home 18/11/02

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 30/01/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: St Joseph`s Rest Home 3 - 7 Bristol Road Brighton East Sussex BN2 1AP     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: Jennie Williams     Date: 2 9 1 0 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 © (2008) 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 Joseph`s Rest Home 3 - 7 Bristol Road Brighton East Sussex BN2 1AP 01273626151 01273570948 zen84109@zen.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Sister Noeleen Ryan Type of registration: Number of places registered: Trustees Of The Sisters Of Mercy care home 17 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Service users will be aged sixty-five (65) years or over on admission The maximum number of service users to be accommodated is seventeen (17) Date of last inspection Brief description of the care home St Josephs Rest Home is a care home providing care for up to seventeen (17) residents over the age of sixty-five (65). Nursing care is not provided at this establishment, however district nurses will visit those residents requiring nursing input. St Josephs is a detached purpose-built property situated in a residential area in Kemp Town, Brighton. The sea and local amenities are within walking distance of the home and there is nearby access to public transport. There is car parking at the home for approximately five cars and there is restricted parking in the adjacent streets. The home is owned by the Trustees Of The Sisters of Mercy, however admission to the home is for residents of any denomination. There is a chapel on site at the entrance of the home that is wheelchair accessible. Rooms are located over three floors. There are Care Homes for Older People Page 4 of 30 Over 65 17 0 Brief description of the care home fifteen (15) rooms for single occupancy and one double room, currently being used for single occupancy. All rooms are provided with en suite facilities. Each floor has a small kitchenette where residents/visitors can make their own refreshments, if they wish. There is a passenger shaft lift available to assist residents to access all areas of the home. There is one wheel in shower and three baths for residents to use, of which two are assisted. There are eight communal toilets located throughout the home for residents. There is a good-sized dining room, lounge room and a conservatory lounge area. Grab rails and level access is available throughout the home to promote residents independence when mobilising. There is a well-maintained garden area that is accessible to residents. Weekly fees range between 380 and 420 pounds. There are additional fees for hairdressing, Chiropody, newspapers and personal toiletries. This information was provided to the CSCI on the 29 October 2008. 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: It should be noted that following recent CSCI consultation, it was identified that service users prefer to be called people who use services. For the purpose of this report, people who use the service will be referred to as residents. This unannounced key site visit took place over seven hours on the 29th October 2008. Evidence obtained at this site visit, previous information regarding this service and information that the CSCI have received since the last inspection forms this key inspection report. Eleven residents, of both genders and over the age of sixty-five years, were spoken with throughout the site visit. All fourteen residents eating in the dining room at Care Homes for Older People Page 6 of 30 lunchtime were met and advised to let the Inspector know if they wished to speak with her privately. Two residents care plans were inspected and specific areas of care were viewed in a further four care plans. A visitor was spoken with. The Registered Manager, deputy manager and five staff were spoken with throughout the visit. Three newly recruited staff files were viewed and training records for staff observed. The environment was briefly observed and some individual rooms were looked at, with individuals permission. Systems for the administration of medication were inspected and the quality assurance and quality monitoring system in place discussed. An Annual Quality Assurance Assessment (AQAA) was sent to the home prior to the site visit. This was to obtain information about the establishment to assist CSCI in the inspection process. The last key inspection was undertaken on the 12 October 2006. An Annual Service Review was undertaken on 27 December 2007. There were fifteen residents residing at the home on the day of the inspection. What the care home does well: What has improved since the last inspection? Action has been taken and is continuing to ensure all three requirements made at the last inspection are addressed. Daily records written provide a better picture of the individual, assisting staff being able to better monitor care provided and the well being of the individual. A quality assurance and quality monitoring system has just been implemented that will assist management to ensure that the home is run in the best interest of residents. This was implemented later than the required timescale made at the last inspection. There was no written evidence at the home to identify that new staff had a Protection of Vulnerable Adults (POVA) and Criminal Record Bureau (CRB) check undertaken prior to commencing employment. This information was provided two days following the site visit. Good practice recommendations made about medication procedures have been addressed to further safeguard residents and staff. Care Homes for Older People Page 8 of 30 The AQAA received identified areas that the home has improved in the last 12 months and areas they have identified in what they could do better. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs and expectations can be met at the home. The pre admission process ensures that only residents whose needs can be met at the home are admitted. Evidence: The home has a Statement of Purpose and Service Users Guide that provides prospective residents with information on the services and facilities provided at the home to make an informed decision if the service can meet their needs and expectations. The home needs to ensure that they send a letter to prospective residents prior to admission stating that they are able to meet the individuals needs. The Registered Manager undertakes an assessment for all prospective residents to ensure that their needs can be met with the services and facilities provided at the Care Homes for Older People Page 11 of 30 Evidence: home. Additional information is obtained from social services and other health professionals wherever possible. The home has implemented new pre admission forms. There was pre admission assessments noted to be in place for two recently admitted residents. The home needs to ensure that the date the assessment was undertaken is identified. There is a key worker system in place and where possible, the home tries to ensure that the key worker is working on the day of admission. One resident commented about the admission process moving in was made easy. Another comment received was its home from home. Staff spoken with confirmed that they felt all residents were appropriately placed at the home, with all needs being met with the services and facilities provided at the home. Staff confirmed that management takes suitable action should someones needs become too much for the home to meet. It was confirmed that there was no one residing at the home from any minor ethnic community, social/cultural or religious groups with any specific needs or preferences. The AQAA identifies that the home is aware of equality and diversity issues and have appropriate policies and procedures in place. Training provided to staff also incorporates equality and diversity issues. The home is owned by the Trustees Of The Sisters of Mercy, however admission to the home is for residents of any denomination. Some residents confirmed that they use the chapel on site. One resident confirmed that their religious needs are being met and commented it doesnt make any difference of religion. Residents spoken with confirmed that they or a representative visited the home prior to moving in. One resident identified that they visited the home twice before moving in. A regulation 26 report viewed identified that one resident expressed doubt about residential care, but has now decided to stay permanently because they have enjoyed the temporary stay. There is no dedicated accommodation to provide intermediate care, however respite is available if there is a place available. The home does not take emergency admissions. 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. Residents needs are being met with the information provided in the care plans on the assessed needs of residents and are generally safeguarded by the medication procedures in place. Residents privacy and dignity are respected. Evidence: The Inspector viewed two care plans and specific areas of care within a further four care plans. There was guidance in place for staff on how to meet the individual needs. Staff spoken with felt that the care plans were detailed. A new staff member confirmed that they found care plans simple and were OK to understand. Any minor shortfalls noted within the care plans were discussed with the deputy manager who confirmed that they will address them. Of the residents that were asked, all confirmed that staff discuss their care with them. One resident commented No need to discuss care as everything flows along. Other comments received about the home were couldnt wish for better treatment, nothing is too much trouble for anyone and wouldnt like to be anywhere else. Care Homes for Older People Page 13 of 30 Evidence: Care plans are reviewed on a monthly basis and the home is trying to get residents or their representatives involved in this process. The home has developed an emergency information sheet on individuals in the event they require to be admitted to hospital. Daily notes are written twice a day and provide more detailed information. It was confirmed that writing clear records is also discussed at staff meetings. There is a key worker system in place. A resident confirmed that they knew who their key worker was. Residents confirmed they have access to health professionals when needed and one commented that they have kept my own GP. There was evidence that health professionals/advocacy services have been arranged for residents. Risk assessments were briefly viewed, as there were no shortfalls noted at the last inspection. Risk assessments are detailed. There are risk assessments in place for those residents who go out into the community independently. This information was not consistent in all care plans and the deputy manager confirmed that she will ensure this is addressed. The AQAA identifies that the home has developed a good working relationship with the falls clinic. Residents are referred to this clinic if their risk assessment identifies that they are at an increased risk of falls. The AQAA also identifies that the home has a good on going relationship with district nurses, whom they often phone for advice on care needs of residents. It was confirmed that there are policies and procedures in place for all aspects of dealing with medication and records are maintained of medicines received into and leaving the home. As recommended at the last inspection, it was confirmed the home has changed the process and there is a clearer audit trail in place for residents who take medication with them when on social leave or leave the home for a period of time. Medication Administration Records (MAR) charts and blister packs observed identified that medication was generally being signed for at the time of administration. There were tablets noted to be left sitting in a pot in the medication trolley with no identification as to what they were or who they belonged to. It was not clear if someone has signed for it and not administered it or if they were left over from last month. The staff member was also unable to confirm why these were left unmarked in the trolley. A bottle of liquid medicine was also noted being in the medication trolley with no identification as to who it belonged to. Residents are provided with an opportunity to self medicate, on a risk assessment Care Homes for Older People Page 14 of 30 Evidence: basis. It is recommended that clear written information be provided on the exact level of self-medication ie: do they order and arrange their own prescription or does the home do this. Senior carers undertake monthly audits of all medicines. It was previously recommended that clearer information be provided on the use of PRN (as needed) medications. This was again discussed with the home that this good practice recommendation should be implemented. There was evidence that accurate records are being maintained of controlled drugs. The home was informed that they need to obtain confirmation that their controlled drugs cupboard complies with and is installed in lines with current legislation. It is recommended that the controlled drugs book index be updated to make it easier to find the correct page where remaining drugs are recorded. It was confirmed that only staff who have received training administer medicines. All residents spoken with confirmed that they felt their privacy and dignity are respected. Staff were observed to have a good professional rapport with residents and were heard to be calling them by their preferred term. Staff were noted to knock on residents doors prior to entering. Comments received from residents were: Im an individual, couldnt be in better place and staff are very kind and helpful. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents lifestyle within the home is their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. Evidence: Residents spoken with confirmed that routines and their lifestyle within the home are their own choice. Residents choose when they wish to go to bed or get up, where they eat their meals, if they wish to participate in activities etc. Residents were observed to move freely within and outside of the home environment at the site visit. One resident commented they bring me breakfast in bed. Staff facilitate activities within the home. The majority of residents confirmed that they felt there was enough activities provided at the home should they choose to be involved. Staff commented that they thought more activities could be provided to the residents. One resident commented could do with more outings when the weather is nice. The AQAA identifies that providing more variety of activities and more activities based on residents choices is an area that the home has already identified as an area for improvement. The home has addressed this by employing an activities person, who is due to commence employment within the next month. The home proposes to have Care Homes for Older People Page 16 of 30 Evidence: joint outings for residents with their sister home in West Sussex. This has not commenced yet. No requirement or recommendation has been made in relation to the provision of activities as the home has already identified this is an area they could do better and are taking action to address this. Visitors are welcomed and encouraged to visit the home. A visitor spoken with confirmed that they were welcomed at the home and that there were no restrictions imposed. A resident also commented that there were no restrictions if their friends/family wish to visit. Residents are provided with a choice in meals. A staff member confirmed that they ask residents the day before what their preference is from the choices for the next day. There is a notice board located in the dining room advising what the choices are for the day. The home also produces small menu cards placed on the tables, reminding each individual what they have ordered for their main meal. Residents were complimentary about the food provided at the home. Comments received were: suits me, marvellous, cater for diabetes, and very good, always have choice. Lunchtime in the dining room was observed to be a social time for residents and staff are nearby to offer discreet assistance if required. The AQAA identifies that breakfast is usually served in individual rooms, however this decision is left to the individual. The AQAA identifies that the home has achieved a five scores on the doors from their last environmental health visit. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents feel comfortable to complain, reassuring them that they are being listened to and that action will be taken, if necessary. Safeguarding Adult procedures and the training of staff ensure residents are safeguarded. Evidence: There is a complaints procedure available at the home. Of the residents that were asked, all confirmed that they know who to speak to and would feel comfortable to raise any concerns. A resident confirmed that resident meetings are held and feels that any ideas/suggestions made are listened to. The AQAA identified that there had been five complaints made to the home within the last 12 months. On discussion with the Registered Manager it was confirmed that there were only four. The AQAA identifies that no complaints were upheld. Records are maintained of all correspondence and actions recorded how the complaints were addressed. Concerns had been expressed to the CSCI, however the individual was happy to address their concerns directly with the home. Staff spoken with confirmed that they are provided with Safeguarding Adults training and this includes whistle blowing. All staff spoken with confirmed that they would feel comfortable to whistle blow within the service. The Registered Manager has undertaken Safeguarding Adults training provided by the local authority specifically Care Homes for Older People Page 18 of 30 Evidence: designed for managers and the deputy manager is trying to access this training for herself. A senior carer confirmed that training in the Mental Capacity Act (MCA) has been accessed, however not all staff have received this training. There are plans in place for all staff to receive this training. The senior carer confirmed that MCA is included in their Safeguarding Adults training. 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. Residents live in a clean, well-maintained and homely environment and are provided with comfortable communal facilities. Evidence: St Josephs Rest Home is a purpose built care home. Rooms are located over three floors and the kitchen and laundry are located in the basement of the home. Each floor has a small kitchenette where residents/visitors can make their own refreshments, if they wish. There is a passenger shaft lift available to assist residents to access all areas of the home. There is also a stair lift available on the rear stairway for use in emergencies. There are fifteen (15) rooms for single occupancy and one double room, currently being used for single occupancy. All rooms are provided with en suite facilities. There is one wheel in shower and three baths for residents to use, of which two are assisted. There are eight communal toilets located throughout the home for residents. There are grab rails placed throughout the home in areas where residents may require some assistance with mobilisation. The home is well maintained and a new water fountain feature has been placed in one Care Homes for Older People Page 20 of 30 Evidence: of the corridors since the last inspection. Residents confirmed that they were happy with their rooms, which were observed to be personalised to reflect the personality and character of the individual. Residents spoken with confirmed that they were able to bring personal items with them when moving into the home. Staff confirmed that there is enough equipment provided at the home, such as manual handling equipment, protective clothing and feel there are enough assisted bathing facilities to meet the needs of residents. There were some areas noted on tour of the environment that need to be addressed. Attention needs to be paid to ensure that extractor fans are cleaned. Hand towels were noted to be in a toilet and one bathroom had no facilities to dry hands. This practice does not promote good infection control and suitable measures should be implemented. Wet towels were noted to have been left on a bath hoist seat, which was found to be stained and in need of a good clean. An empty cleaning fluid container was noted to have been left in a communal bathroom. Written confirmation was provided two days following the site visit that these shortfalls had been addressed. The home was clean and free from offensive odours on the day of the inspection. The AQAA identifies that the home plans to continue with the decorating programme. It also identifies that 15 staff have received training on the prevention of infection and management of infection control. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs are being met with the number and skill mix of staff on duty and are generally safeguarded by the recruitment procedures in place. Evidence: Residents spoken with were very complimentary about the staff working at the home. Some comments received from residents about the staff were: best staff, absolutely friendly and would do anything for you, kind and helpful, lovely and marvellous. Residents and staff spoken with confirmed that there were sufficient numbers of staff on duty at all times. Staff spoken with stated that they enjoyed working at the home and felt that there was good teamwork. There is 14 permanent care staff employed at the home of which nine have completed National Vocation Qualification (NVQ) level 2 or above. Two staff members are currently working towards these qualifications. A senior carer is undertaking NVQ level 4 in care. The AQAA identifies that one part time care staff member has left in the last 12 months. This low turnover of staff assists in ensuring continuity of care is provided. It identifies that 30 care staff shifts have been covered by the homes own bank staff in Care Homes for Older People Page 22 of 30 Evidence: the last three months. It was confirmed that there are three care staff members working in the morning and two carers in the afternoons. One carer works a waking night and there is a sleep in member of staff if additional help is required. Management is also on duty during daytime hours. The AQAA received confirmed that all people that have worked at the home in the past 12 months had satisfactory pre-employment checks undertaken. Three new staff files were viewed. There was no written evidence that all new staff had a cleared Protection of Vulnerable Adults (POVA) First check or Criminal Record Bureau (CRB) check prior to commencing employment, despite a requirement being made at the last inspection. Written confirmation was received two days following the site visit identifying that two staff commenced employment following receipt of a CRB and one staff commenced on a POVA First check. It was reiterated to management that evidence must be available at the home for viewing in relation to all recruitment checks. References are obtained, however the home must ensure that wherever possible, professional references be obtained. For overseas staff, it was noted that the home had not contacted the previous employer. This should not be a barrier in obtaining professional references. Gaps in employment need to be explained. Written confirmation was received from the home two days following the site visit confirming POVA First dates for the staff and identified that action is being taken to address the other recruitment shortfalls noted. This has not been reflected as an outstanding requirement, however will continue to be monitored throughout the inspection process. A staff member confirmed that they felt their recruitment was done fairly. Staff spoken with stated that they are kept up-to-date with mandatory training and are provided with opportunities to undertake additional training relevant to their roles. Staff are encouraged to identify additional training that they may wish to undertake. It was confirmed that new staff undertake an induction programme and the AQAA identifies that the induction programme is set by Skills for Care. 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. Staff and residents benefit from a well managed home and the quality assurance system being introduced will ensure the home is run in the best interest of residents. Evidence: Staff were complimentary about the management at the home and find the Registered Manager fair, approachable and supportive. Staff felt that there were clear roles and responsibilities and clear lines of accountability within the service and with external management. The manager is registered with the CSCI and has the necessary skills, experience and competencies to manage the service. The Registered Manager has undertaken the Registered Manager Award course. The deputy manager has also completed her NVQ level 4 in care. The deputy manager will be commencing the Registered Manager Award course in the new year. Care Homes for Older People Page 24 of 30 Evidence: It was confirmed that a structured quality assurance and quality monitoring system has just been implemented. This evidenced that the requirement made at the last inspection was not complied with within the given timescale. It was confirmed that implementing a system had been delayed as the home was waiting for the Institute (company) to make a decision on a system. Surveys will be sent out to residents, staff and visitors. Surveys have not been developed for health professionals, however the home proposes to ensure their feedback is obtained. It is proposed that an annual survey will be undertaken and specific areas surveyed every six months. Discussions were had with management on ways to analyse the results and ensure these are made available to all people with an interest within the home. Resident and staff meetings are held every month that provides an opportunity for people to raise any issues/ideas. The AQAA did not provide any information on what quality assurance system the home has in place. Discussions were had with the Registered Manager about how some areas of information could be expanded, particularly the summary and ensure all key standards are addressed. The AQAA identifies areas that the service are aware of what they could do better and provides us with information on areas that they have improved within the last 12 months and their plans for improvement in the next 12 months. Monthly reports from a representative of the Institute were noted to be in place. The home is not an appointee for anyone. Residents manage their own finances or make their own arrangements should they require assistance. The home holds some personal allowance for some residents. Receipts are kept of financial transactions. Records viewed evidenced that there is a robust system in place for the safe handling of residents finances. The AQAA identifies that there are relevant policies and procedures in place. It was noted that some have not been reviewed for three years. This is not in line with what they advertise in the Service Users Guide, which states the policies and procedures manual is reviewed on a yearly basis. It was confirmed that the Institute is currently reviewing all policies and procedures. The AQAA identifies that equipment, as applicable, has been services or tested as recommended by the manufacturer or other regulatory body. On tour of the environment it was observed that window restrictors above ground level were not in place and a key to a door leading out onto a flat roof was left in the door. The Registered Manager confirmed that window restrictors had been in place. It is recommended that checking these on a regular basis be added to their health and Care Homes for Older People Page 25 of 30 Evidence: safety checklist to ensure they remain securely in place. Written confirmation was received from the Registered Manager two days following the site visit confirming that all window restrictors had been reinstalled. Staff confirmed that they receive fire training and participate in fire drills. Management confirmed that the homes fire risk assessment has recently been reviewed. The home is in the process of updating all health and safety policies and has recently updated their Control of Substances Hazardous to Health (COSHH) assessment. It was confirmed that all relevant health and safety checks are undertaken on a regular basis. The home reports relevant accidents/incidents to the CSCI as required by regulation. 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 3 14 That written confirmation be provided to service users confirming that their needs can be met at the home. To confirm that following an assessment the care home is suitable for the purpose of meeting their needs in respect of their health and welfare. 22/12/2008 2 9 13 That advice be sought and confirmation obtained that the controlled drugs cabinet is suitable and installed correctly. This is to ensure compliance with current guidelines. 02/03/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 9 That written information be provided on the exact level of self medication. Care Homes for Older People Page 28 of 30 2 38 That regular checks be undertaken to ensure window restrictors remain in place, ensuring service users are better protected. 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 © (2008) 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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