Inspection on 18/11/08 for St. Michael`s Home

This inspection was carried out on 18th November 2008.

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

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

Other inspections for this house

St. Michael`s Home 02/11/09

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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. Michael`s Home 251 Warwick Road Olton Solihull West Midlands B92 7AH     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Julie McGarry     Date: 1 8 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. Michael`s Home 251 Warwick Road Olton Solihull West Midlands B92 7AH 01217079697 01217079697 dmattu@hotmail.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Ms Anne Mary Farthing Type of registration: Number of places registered: Dr Gurdial Mattu care home 21 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users to be acommodated is 21. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 21 Date of last inspection Brief description of the care home St. Michaels is a purpose built care home, which was registered in November 1993. The home, which is privately owned, is on the corner of a main road and is easily accessible by public transport. There is a large car park. The home provides permanent placements for up to 21 frail older people over the age of 65 whose care needs can be met within a residential setting. The home is located over two floors and comprises of 19 single rooms and one double room. All of the bedrooms are fitted with a wash hand Care Homes for Older People Page 4 of 30 Over 65 21 0 Brief description of the care home basin. Bedrooms may be decorated and furnished to the choice of the occupants. The home has a shaft lift for ease of access to the first floor. The home has two assisted bathrooms and one assisted shower room. There are adequate numbers of toilets throughout the home some large enough to allow full assistance from staff. On the ground floor communal facilities comprise of an open plan small sun lounge, lounge and dining area and an additional small lounge. There are limited garden/patio facilities to the property. Up-to-date information relating to the fees charged for the service is available on request from the home. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 1 star. This means the people who use this service experience Adequate quality outcomes. The focus of inspections undertaken by us is upon outcomes for people who live at the home and their views of the service provided. This process considers the homes capacity to meet regulatory requirements minimum standards of practice and focuses on aspects of service provisions that need further development. This report uses information and evidence gathered during the key inspection process which involves a visit to the home and looking at a range of information. This includes inspection activity, notifications made by the home, information shared from other Care Homes for Older People Page 6 of 30 agencies and the general public, and a number of case files. The manager supplied the commission with an AQAA Annual Quality Assurance Assessment in November 2008. Information from this has been used to make judgements about the service and have been included in this report. Surveys were sent to people who live at the home. Three surveys we returned, the findings of these surveys have been included in the report. This was the homes first key inspection of 2008/2009 and since new owner took over the running of the home in June 2008. The inspection visit was unannounced (we did not let the home know that we were coming) and took place on 18th November between 8:30am and 5:30pm. The inspection involved observations of and talking with the people who live at the home, the staff on duty, the manager and the owner. Three people were identified for close examination by reading their care plan risk assessments daily records and other relevant information. This is part of a process known as case tracking where evidence is matched to outcomes for people. A tour of the environment was undertaken and home records were sampled including staff training and recruitment health and safety and staff rotas. We would like to thank the people who live at the home, the owner, the manager and staff for their hospitality and co-operation during the inspection visit. What the care home does well: What has improved since the last inspection? What they could do better: People living at the home would benefit from continued redecoration of the home to ensure it is well maintained. Care plans must be completed for people after they move to the home. This is to make sure that peoples needs are identified and staff know how to care for them. The range of social activities and outings available to those who live at the home could be improved. In particular, the provision of more opportunities that meet the individual needs and preferences and those who remain in their rooms. The home needs to develop effective ways of assessing and monitoring the quality of the service. This is so that shortfalls are identified are improved on, and the quality of the service is kept under constant review. The laundry service and infection control management in the home needs to improve to protect the welfare of residents and staff. It is recommended that all staff have refresher training to make sure that their knowledge and skills are up to date and reflect current best practice. The statement of purpose and service user guide needs to be reviewed and updated to reflect the new ownership of the service. Care Homes for Older People Page 8 of 30 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. People can be confident the service can support them because they have had a full assessment of their needs before moving there. There are no care plans in place for people who have recently moved to live here. This could lead to inconsistent care being provided. Evidence: The service assesses peoples needs in a detailed way prior to moving in. Two peoples files show that the assessment questions are detailed and that their relatives visited the home. The manager is very clear about the assessment of peoples needs to ensure it is the right service for them. Two peoples files looked at, neither contained draft care plans or risk assessment plans to guide staff on how peoples needs should be met. There was however detailed information in the pre admission assessment that included information about identified Care Homes for Older People Page 11 of 30 Evidence: risks. Staff spoken to were knowledgeable about both peoples care needs. Files also contained pre-admission information provided by professional health and social care agencies and incorporated into care plans. The service has a detailed statement of purpose and Service User Guide which we saw however information contained in both documents relate to service when it was run by the previous owners. Both documents need to developed to provide people with the information needed to help them make decisions about moving to the service. One person who uses the service has a contract with social services but not a personalised one with St Michaels. The service needs to ensure each person has a contract for their stay there, so they know what they can expect from the service. 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. People are supported by respectful staff to maintain their abilities and dignity. Medication is being managed well. There are misisng care plans and risk assessment plans to guide staff on how needs should be met, this could lead to inconsistent care being provided. Evidence: People able to tell us said that they were happy in the home. The staff are very nice gentle and caring. The food is good and we have a good choice. I feel safe here. I get myself washed and dressed, if I need any help the staff are there. The care is brilliant, I go to bed went I want to, sometimes this is at 6.30pm. One relative spoken to commented Wonderful home, recommend it to any one. Staff know the people and relatives well, their care plans, reasons for their medication, Care Homes for Older People Page 13 of 30 Evidence: and equipment. We saw good plans that encourage the expression of views and feelings. Religion and culture are assessed although this could improve. The home uses this information to provide care the way it is wanted to maintain peoples self esteem monitor and identify changes. We know this from daily records charts and reviews held with people and their families. People make choices about food, personal care, clothing and medication. They sometimes refuse and this is respected. Key areas such as risk of falls, nutrition, and skin integrity are assessed and reviewed and there is evidence to show professional help is sought. For example, one persons care plan states that there is a risk in relation to pressure sores. The risk assessment plan guides staff to monitor skin, and contact district nursing should any areas of redness appear. Another person is at risk of self harm. There is a care plan and risk asessment in place to identify the triggers to this behaviour and actions staff need to take in response to minimise self harm. As previously mentioned, there were care plans and risk assessment plans missing from two peoples files who have recently moved to live here. A further three personal care and health records were looked at in detail and several further records were sampled. Each person has an individual plan about what they are able to do independently and the assistance required for staff to help them maintain their health wellbeing independence and dignity. Staff record and pass information to each other daily about peoples conditions, moods and behaviour. We found that sometimes staff are more up to date with peoples needs than their care plans and risk assessment plans. Health professionals are often in the home and people attend appointments. We saw a good plan to support one person who is at risk of self harm. And staff spoken to are clear about the triggers that can lead to self harm. Involvement from specialist professionals, for example, the Community Psychiatric Nurse and Psychogeriatrician were recorded. Personal care is discrete and peoples dignity maintained by adjusting their clothing, knocking their doors and using preferred names. We saw good moving and handling plans with people with mobility needs and who need support to move around safely within the home. We also saw risk assessment plans for people at risk of pressure sores. This information guides staff on what to look for and action to be taken should they have any concerns. Staff are trained in the medication policies and procedures during induction and there is a medication training programme. The medication records were seen and showed Care Homes for Older People Page 14 of 30 Evidence: that the amount of medicines brought into the home tallied with the amount administered. All medication including controlled drugs are stored safely and appropriately. There is however no record of temperature recording of medication stored. Medication must be stored below 25 degrees to ensure the stability of the medicines. A medicines fridge was available with daily recordings of the temperature using a maximum minimum thermometer. There is a list of staff signatures and initials available to assist in auditing and quality assurance. Those people living at St Michaels looked well cared for and were clean their hair had been combed and nails were trimmed and clean. They were well presented and wore clothes that were suited to the time of year. 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 use this service are able to participate in social activities and are given choices including choice of meals provided to maintain their quality of life. Evidence: Three people spoken to said that they were able to follow their preferred routines such as getting up and going bed. People who use this service are able to participate in some social activities and are given choices including choice of meals provided to maintain their quality of life. Staff know and record peoples likes, dislikes, moods and personal routines such as what time people like to get up and go to bed at. Routines are flexible, although people may need familiar routines to settle in and for orientation. Peoples interests are recorded along with important relationships religious and cultural needs. For example, one person likes football and has been able to watch recent football matches on the television. There is a choice of religious service in the home. People spoken to confirmed that they have the opportunity to receive Holy Communion should they wish to do so. St Care Homes for Older People Page 16 of 30 Evidence: Michaels assists people to maintain relationships with family and friends. On the day of the inspection we saw staff initiate a group activity in the afternoon. People were also offered the choice to sit and listen to music in the lounge. One relative commented that his father enjoyed the type of music being played in the lounge that day. The manager informs us that the home has arrangements for external support every Wednesday where people are offered the opportunity to join in progressive mobility. Records state that All residents participate in this activity however, the manager informs us that this may not always be the case. Records about the activities people are offered and participate in are limited. More detailed information in each persons case file about their interests and relationships which would assist staff to deliver person centred care. We spoke with people who use this service and they confirmed that they are able to join in the progressive mobility each week and they also play various board games dominoes for example. Two people spoken with told us that they would like more opportunities to do more and varied activities. The manager informs us that there is no structured program of activities for each week. We are told that activities are arranged depending on peoples preferences each day. There was no evidence to tell us how the home was ensuring the social interests of one person who remained in their room through the day were being met. The cook is given information on peoples favourite foods dietary needs and foods to avoid. Every meal has a daily choice and on the spot alternatives. The menus provided by the home show a four week rolling menu. The breakfast and lunch are prepared by the homes cook. Care staff prepare the meal in the evening. On the day of the inspection, the inspector joined residents for a meal. The main meal was a choice between chicken or lamb with mashed potatoes, roast potatoes and various vegetables. A choice between ice cream with chocolate sauce and trifle was served for dessert. This meal was well cooked and presented. Staff were seen to offer support when needed in a discrete and respectful manner. We observed good practice from a member of staff supporting one person who is partially sighted. It was evident that the staff member was aware of impact of the sun shining through the window may have upon their ability to see and eat their meal. The staff member spoke with this person about pulling the curtain over to block the sun and sought the agreement of others sitting at the table before doing so. 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. Complaints and concerns are taken seriously and acted upon. The home uses the council adult protection process to prevent and safeguard people from abuse. Evidence: Since this service registered under new owners in June 2008, there have been no complaints made to the home or the commission. The complaints procedure is in the homes Service User Guide in every bedroom. People spoken to were clear about how they could make a complaint and said they were happy with their stay so far. One person told us Ill talk to staff if Im unhappy. The manager informs us that people who live at the home are able to inform staff of their views or complaints through residents meetings or via the homes Grumble book. The Grumble book was seen and enteries relate to missing items of laundry. The home has an adult protection policy to give staff direction in how to respond to suspicion allegations or incidences of abuse. Staff training records were seen to demonstrate that most of the staff had received training in recognising and responding to signs of abuse. Discussion with the manager established that she was familiar with local Adult Safeguarding Procedures and how to refer allegations of abuse. Care Homes for Older People Page 18 of 30 Evidence: Staff members on duty spoken to, had covered protection and whistle blowing procedures as part of their and NVQ (National Vocational Qualification) and knew how to report any concerns should this become necessary. However staff records tell us that not all staff have accessed training in realtion to protection and whistle blowing procedures. At the time of the inspection there had been no allegations of abuse made to the commission. The home does not manage or store peoples money on their behalf. 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 generally clean, comfortable and safely maintained. People are able to bring their own possessions, and equipment is provided for their needs. Procedures in place for the management for infection control are not robust. Evidence: A tour of the building was undertaken at the start of the inspection. The inspector was shown around the home by one person who lives there. The home has bedrooms on the ground and first floors. Each person has a single room with ensuite wash basin. Those rooms visited were personalised to a high degree displaying a number of individual possessions including pictures and photographs. There is a passenger lift and staircase giving access to the first floor to enable easy access for people with limited mobility. We saw that the home is secure. There are window restrictors to prevent people falling. The front door is locked to prevent intruders and for safety of people who would be at risk of walking out onto the busy road. Most areas of the home were clean to a good standard. However the home would benefit from further updating and decoration in such areas at the bathrooms. Further maintenance work needs to be carried out, for example, some strip lights in peoples Care Homes for Older People Page 20 of 30 Evidence: rooms need to be replaced to ensure all lights are in good working order. The owner informs us that new arrangements are being put into place for a handyman to be made available to the home on a permanent basis to address any maintenance matters. People who live at the home have a choice of two lounges to relax in or their own rooms. On the day of the inspection one person told us that people can sit where they want in the lounge, however, most people have a particular seat they like to sit in for their meals. On the day of the inspection, measurements were being taken for new carpets to be fitted in the upstairs hallways. The owner confirms that new carpets for specified areas upstairs are due to be fitted within the next week. There is no fire safety certificate available at the home, the manager tells us that a detailed fire risk assessment has been completed. This was not seen on the day of the inspection, however the manager agreed to forward this to us within an agreed timescale. This was received by the commission. On the day of the inspection, the home was visited by representatives of a company contracted to carry out fire safety tests. Required signs were put in place at exit doors and at the lift. The kitchen was clean and well organised. However, there is no evidence of records being maintained of the fridge and freezer temperatures to show that appropriate temperatures are maintained for ensure good food safety. The laundry was visited. Care staff bring soiled clothing to the laundry room in red disposable plastic bags. The manager and staff explained that they have had problems with managing the laundry service as they have not consistently had a working washing machine or tumble drier. The manager tells us that the home has had to make arrangements for the laundry to be done by independent laundry services. On the day of the inspection, poor infection control management was observed when a red laundry bag for soiled clothes was left lying beside wet clothes that have been cleaned. We did however see that a new tumble drier was delivered on the day of the inspection. The owner informs us that arrangements have been made for new laundry facilities to be put into place at the home the week following this inspection. The manager tells us that she has joined a Tackling Health Care Assocaited Infections Outside of Hopsital health programme to better inform her of good infection control managment. Disposable gloves were seen to be readily accessible for each member of staff. One member of staff requires a specfic type of disposable glove and this has been made available to them, however from coversations with staff, this has not always been the case. Products used for cleaning are stored away safely in a locked room. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient numbers of staff on duty to meet the needs of the people living in the home. The homes recruitment policies are robust. Training is provided to make sure staff have some knowledge and skills to deliver a service to the people who live at the home. Further training needs to be offered to ensure all staff receive up to date mandatory training. Evidence: Staff were seen to interact well with people living in the home during lunch residents were at ease making requests and asking for assistance. The personnel file of the most recently recruited member of staff was seen. We saw evidence that this member of staff was recruited following completion of a Criminal Record Bureau (CRB), satisfactory Protection of Vulnerable Adult (PoVA First) checks and two satisfactory references before they started working in the home. These robust recruitment practices should safeguard people living in the home from the possibility of abuse. Evidence was also seen that staff have access to an induction program when they start working at the home, however further development of this in line with the Skills for Care would give staff a better foundation when they start work. Staff receive job descriptions and contracts that showed what they are expected to do. Care Homes for Older People Page 23 of 30 Evidence: There is no written evidence that staff are receiving formal supervision. The current manager has informed that this will now become standard practice for staff. The training records of staff working at the home were seen and demonstrate that staff receive mandatory training. It was evident that staff have opportunities to attend various training programs, however it is not clear if all the training programs are by verified trainers. Not all staff have attended training in safeguarding. The manager states that the home is fully staffed. There are ten carers, not including the cook, domestic and laundry assistant. The rota shows that there are three care staff each morning, afternoon and evening. There are two waking night staff. Staff spoken to feel that there are adequate staff on duty to meet the needs of the people who live there. Information supplied by the manager state that 8 members of care staff are qualified to National Vocational Qualification in Care Level 2 (NVQ level 2). This is above the national Minimum Standard for 50 of staff to be qualified. This should mean that residents benefit from having their needs met by staff that are appropriately experienced and qualified. 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A person with the appropriate qualifications and who has management experience manages the home. The home does not have a formal quality assurance system. The new owner has yet to undertake monthly visits to look at how the home is performing and make recommendations for development in the care at the home. Management systems and procedures need to develop and staff competence so that peoples health and wellbeing are proactively protected. Evidence: The home has a qualified and experienced manager registered by CSCI in post. A record is maintained in the home of any accidents or incidents that happen to people living in the home. A recent incident involving a person living in the home evidence Care Homes for Older People Page 25 of 30 Evidence: that the home is not ensuring that the Commission is informed of all accidents, incidents or events, which affect the well being of people living in the home. The manager needs to be clear when notifications to the commission are required. The Annual Quality Assurance Assessment (AQQA) completed by the manager and was done so to a good standard. Information provided was supported by a range of evidence, and the Annual Quality Assurance Assessment (AQAA) informs us about changes the home has made and where improvements still need to be made. The home does not have a formal quality assurance system. The owner is not undertaking monthly visits to look at how the home is performing, or providing recommendations for development in the care. Th owner informs us that questionnaires for people who live here and their relatives are currently being devised to ensure the home offers people opportunities to feedback any comments about the service. As previously noted, there is no written evidence that staff are receiving formal supervision or appraisals. This needs to be put into practice so that management ensure staff practice meets peoples needs, policies and procedures are followed. The service does not hold residents personal monies or valuables for safe keeping so standard 35 is not applicable and was not assessed. People are invoiced for additional costs such as hairdressing or chiropody. In general the home is well run and has a person-centred approach that benefits people in their care. Management seek to continuously learn and improve. There are management systems in place that need development so that people using the service have consistent quality in all aspects of the service. In many respects human resource management is good, however we discussed robust action needed with the manager and owner regarding staff supervision, appraisal and determining staff are competent. Care Homes for Older People Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 17 Each individual must have a detailed care plan to assist staff to meet all their needs. This will help to ensure that staff have the information to meet peoples care needs in an appropriate and consistent way. 31/12/2008 2 26 16 The home must have adequate infection control measures in place. This will protect the welfare of residents and staff. 31/12/2008 3 30 13 All staff working in the home 06/02/2009 must be trained in all areas related to Safeguarding Vulnerable Adults. This will ensure that people who use the service are protected from harm and abuse. Care Homes for Older People Page 28 of 30 4 33 24 The management of the 31/12/2008 home must develop effective ways of assessing and monitoring the quality of the service. This is so that shortfalls are identified, are improved on and the quality of the service is kept under constant review. 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 1 The statement of purpose and service user guide needs to be reviewed and updated to reflect the new ownership of the service. The purchase of a maximum, minimum thermometer is advised to accurately read the maximum, minimum and current temperatures on a daily basis to ensure that the medicines held are stored in compliance with their product licence to maintain their stability. Increase the range of social activities and outings available to those who live at the home. In particular, provide more opportunities that meet the individual needs and preferences of those who live there and those who remain in their rooms. The manager should ensure that there is an ongoing program of redecoration to maintain the home to a good standard. Records should be mainatined maintained of the fridge and freezer temperatures to show that appropriate temperatures are maintained for ensure good food safety. These records should be available for inspection. Regular appraisal of staff performance should take place so that management ensure staff practice meets peoples needs, policies and procedures are followed. 2 8 3 12 4 19 5 19 6 36 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!