Inspection on 09/12/08 for The Hollies

This inspection was carried out on 9th December 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

The Hollies 12/01/07

The Hollies 19/12/05

The Hollies 18/07/05

The Hollies 25/01/05

The Hollies 25/08/04

The Hollies 20/02/04

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: The Hollies 86-90 Darnley Road Gravesend Kent DA11 0SE     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: Susan Hall     Date: 0 9 1 2 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 28 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 28 Information about the care home Name of care home: Address: The Hollies 86-90 Darnley Road Gravesend Kent DA11 0SE 01474568998 01474332980 evergreenhce@btinternet.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Peter Anthony Rogers,Mrs Helen Elizabeth Rogers care home 40 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home The Hollies is located close to local shops, and Gravesend town centre is within walking distance. The premises were originally two semi-detached houses which have been converted and extended into one large building. The extension to the home is modern and purpose built. Most of the bedrooms have en-suite facilities. The home is decorated to a high standard and is comfortably and attractively furnished. There are two large living rooms, two smaller quiet rooms, a separate dining room and a large conservatory. The home has a large attractive garden with a patio area and lawn. The home has a passenger lift; and handrails are fitted in halls and corridors. Current fee levels can be obtained from the manager. 0 Over 65 40 Care Homes for Older People Page 4 of 28 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 service is assessed as having a rating of GOOD, 2 stars. This was a Key inspection, which takes into account all information obtained about the service since the last key inspection. This includes letters and telephone calls, any complaints or safeguarding issues, legal notifications which the home is required to send to CSCI, and the Annual Quality Assurance Assessment (AQAA) which all care services complete annually. The visit to the home was carried out by one inspector, and lasted for seven hours. During this time, we (i.e. CSCI) inspected documentation such as care plans, staff files, maintenance records and the staff training records; viewed all areas of the home Care Homes for Older People Page 5 of 28 including some of the bedrooms; talked with nine staff, and one visitor; and chatted with six residents, and met others briefly. The home has a relaxed and friendly atmosphere, and the ethos is to enable residents to decide and follow their own preferences on a day to day basis. Residents said that they are well looked after; the food is very good and there is plenty of choice; and they have enough opportunity for entertainment and activities. The home is kept clean in all areas and is a credit to the domestic staff. Furniture and furnishings are of a good standard, and there are different communal areas where residents can sit. The gardens are spacious and well maintained. The home has not received any formal complaints since the last inspection. One referral had been made to the Social Services Safeguarding Adults team, and was currently under investigation. Senior staff are helpful and cooperative with providing information to other authorised agencies. What the care home does well: What has improved since the last inspection? What they could do better: Care plans could include more detail in some areas, and could be further developed. Daily records should include the time of writing, as well as the date. Some assessments were viewed which had not been signed. The management need to decide how to demonstrate compliance with the Mental Capacity Act with documentation about relevant subjects in care plans. This is already under consideration. Some issues regarding medication need attention as follows: Medication charts must have two signatures for any handwritten entries. The home does not have a controlled drugs (CD) cupboard or register. It is now a requirement that all care homes (i.e. not just care homes with nursing) store any controlled drugs in an approved CD cupboard. The home had a controlled drug on the premises. Schedule 1 and 2 controlled drugs Care Homes for Older People Page 7 of 28 must also be entered into a register with two signatures. It is also good practice for schedule 3 drugs to be included in a CD register. The complaints procedure was not complete in the service users guide, and was not easily available. This needs to be amended to include timescales as per regulation 22. There was no complaints log in place and a complaints log must be available for authorised persons to view; however, the administrator took immediate action to rectify this. It is recommended that staff receive specific and separate training in the recognition and prevention of abuse. This is currently taught as part of training in other subjects, but would be more clearly defined if treated as a subject in its own right. It would also demonstrate more clearly that all staff have been given a clear understanding in regards to this. 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 8 of 28 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 9 of 28 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 provides good information for prospective residents. Satisfactory assessments are carried out to check the suitability of the home for each placement. Evidence: The Statement of Purpose and the Service Users Guide contain the required information, and are clearly written documents conveying the aims, objectives and ethos of the home. A copy of these documents is on display in the entrance hall, and are therefore accessible to any residents or visitors. The service provides a home for older people from any race or religious persuasion, and is non-discriminatory. Residents have an ongoing say in the life of the home, and their rights are upheld. The complaints procedure is included in the documentation, but this was incomplete, and the administrator said it would be amended immediately. The details of this are entered in the section on Complaints and Protection. Care Homes for Older People Page 10 of 28 Evidence: The Registered Manager or the Home Manager carry out a detailed pre-admission assessment for all residents. Three of these were viewed and contained comprehensive information to determine that the home would be able to meet the residents needs. Prospective residents are invited to view the home, and to stay for a day to meet staff and other residents, and see how the home runs. All residents are given a contract, and this clearly outlines the fees payable, what is included in them, and the terms and conditions of residency. There is an initial trial period of four weeks. Some residents are initially admitted for respite care, but then decide to stay permanently. Care Homes for Older People Page 11 of 28 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. Care plans are drawn up to show the individual needs and lifestyle for each resident. Personal and health care needs are met by the home. Evidence: Care plans are drawn up with the involvement of the resident and their relatives as applicable. Four care plans were examined, and were seen to contain assessments about each aspect of residents individual lifestyles. Admission assessments are completed for physical health care needs, recreational, social, mental health and psychological profiles. There is a care plan overview which shows the main care needs on one page, and this is a quick reference for care staff. Physical health data includes support needed with washing, dressing, toileting, mobility, and dietary needs. Details such as the amount of help needed with oral health and foot care, are included. Residents were seen to be well groomed, assisted with shaving where necessary, and with nicely ironed clothes. A hairdresser is employed for three to four days per week in house, and residents value this facility. Care Homes for Older People Page 12 of 28 Evidence: Staff were observed as treating residents with courtesy and affection. Care plans show details of the persons ability to communicate, to understand information, and if they have impaired sight or hearing. Lifestyle assessments show their likes and dislikes in regards to television, radio, music, social activities etc, and if they have any family involvement. The psychological profile provides a tick list for difficulties previously known about, such as anxiety, depression, mistrust, suicidal tendencies or paranoia. The mental health check shows the persons ability to concentrate, if they are orientated in place and time, and if they are able to plan their own day unassisted. Care plans are divided into day care plans and night care plans, with a short section for each subject. The day care plans could be improved by providing a separate page with more details for each subject, but still contained satisfactory information. They are reviewed on a monthly basis, and are updated several times per year and as things change. The home has a good rapport with local GP practices, and GPs and district nurses are asked to visit as appropriate. A chiropodist visits on a regular basis, and an optician and dentist are available as needed. There is an exercise class each week, which encourages residents to maintain their mobility. All residents are provided with a call bell which they carry with them. These can be worn on cords around the neck, or carried on walking frames or in handbags according to choice. Residents are enabled to administer their own medication if they are assessed as safe and able to do so. There is a lockable facility for each resident in their room. The home has a clinical room for the storage of other medication, and care staff are suitably trained in medication management and administration. They do not carry this out until they are assessed as trained and competent to do so. The clinical room is suitable for its purpose, and storage cupboards were seen to be neat and tidy. One medication trolley was inspected and was in good order. Most medication is administered via the nomad cassette system. Medication Administration Records (MAR charts) are well completed, except that hand written entries were not signed (for example, new medication prescribed or changes to dosage). These must be signed by two appropriate staff, showing accountability for the items written on to the MAR charts. The home does not have a controlled drugs cupboard, and it is now a requirement for all care homes to store controlled drugs (CDs) in a cupboard that meets the requirements of the Misuse of Drugs Safe Custody Regulations 1973. The regulations Care Homes for Older People Page 13 of 28 Evidence: specify the quality, construction, method of fixing and lock and key management for the cupboard. The home had a schedule 3 drug on the premises, and so it is a requirement to purchase a CD cupboard. The clinical room contains a drugs fridge which is correctly used for the storage of certain items of medication. The fridge temperature is checked daily. Senior staff have been trained in the Mental Capacity Act, and the implications of this towards residents in their care. They are in the process of working out how to use written evidence in care plans to show compliance with this, demonstrating if residents have the ability to make decisions for themselves. There is a recognition that some residents may be able to make decisions such as choosing their clothes, but may no longer have the ability to make life decisions such as end of life care, or attending hospital. End of life care is discussed according to the perception of each individual resident, as some do not wish to discuss this, while others are happy to do so. The homes ethos is to enable residents to stay at the home, so long as the staff can continue to meet all care needs. Care Homes for Older People Page 14 of 28 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 are enabled to live according to their chosen lifestyles. The home provides a suitable range of activities and entertainment. The residents benefit from a nutritious and varied diet. Evidence: Residents are enabled to plan their own days according to choice, which includes getting up and going to bed when they wish. Some residents like to stay up until after midnight watching a film together sometimes. The home has large lounge and conservatory areas, with different seating areas, and also a small conservatory known as the bar; and a quiet room on the first floor. This provides a good variety of places to sit, as well as their own rooms if they wish. Residents are free to come and go as they please on a risk assessed basis, and are asked to inform the staff what time they expect to return to the home. The home has a weekly exercise class; and daily activities for items such as quizzes, bingo, arts and crafts and board games. These are currently managed by two care staff. The home has a minibus and a six seater car to use for transporting residents to the shops, or for appointments or to the library. There is a trolley shop kept on site, so Care Homes for Older People Page 15 of 28 Evidence: that residents can purchase everyday items such as sweets and toiletries without having to go out. One of the providers also maintains a sale rail of new or nearly new clothes, so that residents can buy clothes on site if they wish to do so. Entertainment in the home is provided at least once every two weeks, and includes singers and musicians, and events such as garden parties, barbecues, carol singing, quiz nights and a Christmas Fair. The staff were in the process of rehearsing for a pantomime, which they put on each year. Outings are arranged regularly to places such as the Southend seafront for fish and chips, visits to the theatre, and visits to pubs for lunch out. Visitors are welcome at any time, and can stay for meals if the resident would like this. The management ensure that residents religious needs are met, enabling them to go out to churches, or have visits from ministers in the home. The home has a chef and two other cooks to manage the catering. Residents said that the food is good, and there is always plenty of it. Cooked breakfasts are served three times per week. Residents menu choices are added to the current menu at regular intervals. The menus take seasonal changes into account. There is always a choice of main meal and dessert, and residents are asked daily what they would like for tea, from a wide variety of options. Snacks are available at any time, including night times, and hot drinks are served at regular times throughout the day. Meals are usually served in the dining areas unless someone is ill. This is discussed during the pre-admission and admission processes. The kitchen was seen to be clean and well organised. There are set daily and weekly cleaning programmes in place. Cooks are on duty from 8 a.m. until 6 p.m., and are assisted by a kitchen assistant each day. Care Homes for Older People Page 16 of 28 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 know that they are listened to, and that any concerns are addressed quickly and dealt with. However, the home needs to amend the complaints procedure and make it more easily accessible. Evidence: The home has an open door policy, and residents know that they can talk to the Home Manager, or the Registered Manager and Providers at any time. One of these senior staff is always on call, including weekends, and will visit the home immediately if needed. There are regular meetings for residents, and they feel able to freely voice their opinions and ideas. The complaints procedure is included in the statement of purpose and service users guide, both of which are kept on display in the entrance hall. However, the procedure did not include timescales for a response to the complainant, and only stated that complainants should go to the manager first, and then CSCI or the Ombudsman if not satisfied. It would be clearer to state that complaints can be made at any time to the Home Manager, then the Providers, or Social Services. CSCI and the Ombudsman can also be contacted if complaints are not resolved. The procedure should clearly include addresses and phone numbers for each person or authority. It would also be helpful to have the procedure on display, so that a complainant would not have to go looking for it in another document. Care Homes for Older People Page 17 of 28 Evidence: There is a complaints form available to complete details, and complaints are dealt with individually and confidentially. However, complaints forms have to be requested, which may be difficult for some people. This practice could also be simplified. The home did not have a complaints log in place, and the management reported that there had not been any complaints since the last inspection. The regulation states that all services must have a complaints log available for authorised persons to view, and when this was pointed out, immediate action was taken to put a complaints log into place. Day to day concerns are recorded in the daily diary, and are dealt with immediately. CSCI received a concern from someone on the day of the inspection, and as the issue could have implications for other residents, this was referred to the Social Services safeguarding adults team for investigation, as is agreed according to multi-agency protocols. The management expressed their willingness to fully cooperate with this investigation. Staff training includes recognition of different forms of abuse, and this knowledge is delivered through training sessions for all subjects. We recommended that it would be advantageous to the home to set this up as a separate training subject, so that the home can clearly demonstrate that each staff member has received this training. Care Homes for Older People Page 18 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises have been sensitively developed into one large home from three houses and an extension. The building and gardens are well maintained, and the furniture and furnishings are of a high standard. Evidence: The premises have undergone a major refurbishment in recent years, and are well designed to meet the needs of the residents. Bedrooms are situated in different wings, all of which have easy access to bathroom and toilet facilities. There is a passenger lift between floors, as well as different stairways. Accommodation is provided in thirty-four single rooms, of which twenty-eight have ensuite facilities; and in three double rooms, two of which have en-suite facilities. The en-suites all have a toilet and wash basin, and many also have a shower unit. There are sufficient numbers of communal bathrooms and a shower. Only one of the bathrooms has an integral hoist, and it may be worth considering fitting a hoist for another bath, as most residents do not feel safe using a bath without a hoist. The bath hoist concerned is old and damaged, and the providers have already decided to replace it as soon as possible. Other equipment available includes grab rails and hand rails, raised toilet seats and commodes. One commode was seen to be rusty, and the Care Homes for Older People Page 19 of 28 Evidence: provider said this would be repaired or replaced. Bedrooms are decorated as the need arises. Residents are able to choose the colour they wish for their room and furnishings when redecorating is taking place. A number of bedrooms were viewed, and were seen to be personalised according to residents wishes. The home is kept clean in all areas. There are usually two domestic staff on duty each day, with a third staff member coming in for carpet cleaning and window cleaning on three days per week. The laundry is situated through the designated smoking room on the ground floor, and is small, but well organised. There are two commercial sized washing machines and two tumble dryers. Clothes are also dried outside in good weather. The laundry is carried out by the care staff as one of their duties. Care Homes for Older People Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a stable staff team, who are well trained, and provide competent care and attention. Evidence: The home usually has a staffing level of six carers on duty in the mornings, four in the afternoons, three at night and a fourth carer sleeping in, in case of emergency. This is when the home is fully occupied. Senior care staff are known as team leaders, and there is always at least one team leader on each shift. Team leaders have completed NVQ 3 in health and social care, or are in the process of completing it. The care team are led by the Home Manager, who oversees all day to day care duties. The providers, Mr. and Mrs. Rogers, (of whom Mr. Rogers is also the Registered Manager), are in the home on most days, and are actively involved in all aspects of the running of the home. The management are also assisted by a full time administrator. All new care staff are expected to study for NVQ level 2, and the home currently has over eighty per cent of care staff trained to NVQ 2 or higher. This is excellent. The management also encourage other staff to study for NVQ training relevant to their posts. The administrator has completed NVQ 4 in management, and other staff such as catering and housekeeping staff have also completed NVQs. Care Homes for Older People Page 21 of 28 Evidence: Recruitment procedures are well managed. We examined three staff recruitment files, and found that all required checks are carried out, including POVA first, Criminal Record Bureau (CRB) check, two written references, proof of identity, and confirmation of any training. Staff are requested to provide a full employment history and to complete a medical questionnaire. If any information does not appear to be complete, the applicant is questioned about this at interview, and interview records are retained. All staff go through a comprehensive induction programme and a probationary period of thirteen weeks. They are supplied with a staff handbook which outlines staff roles and responsibilities, and has some key policies included. Job descriptions are provided, and an interim contract until the probationary period has been completed. Staff have a review with the Home manager during their probation, and there is another review at the end of this time before confirming their permanent role. During their probationary period, staff carry out all mandatory training i.e. first aid, fire awareness, health and safety, moving and handling and basic food hygiene. There are ongoing training courses in other subjects to ensure that staff keep up to date with their skills and increase their knowledge. The home employs a training consultant to manage all of the training. Other training includes items such as the Mental Capacity Act, continence care, medication management, and funeral awareness. All staff have an individual training and development plan. Care Homes for Older People Page 22 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is run by a competent and experienced manager. Evidence: The Registered Manager is also one of the providers, and is a trained nurse RGN and RMN. He has many years of experience in owning and running care homes, and is assisted by his wife (who is the other provider), the Home Manager, and the administrator. The Home Manager oversees the care given and is trained to NVQ level 3 and as an assessor. She has also completed training courses in dementia, Alzheimers disease, adult abuse, and palliative care. They work closely as a management team, and staff spoke highly of the Registered Managers commitment to the residents and the staff. There are regular staff meetings for different parts of the staff team such as night staff, kitchen staff etc. as well as general staff meetings. Staff have three monthly reviews, which is the homes way of managing one to one formal staff supervision. These include time to discuss training Care Homes for Older People Page 23 of 28 Evidence: needs and opportunities. All staff have yearly appraisals, which include a self appraisal as well. Residents finances are managed by themselves or their appointed representative. The home keeps small amounts of pocket monies on their behalf if wanted, and good records are maintained for these. They are stored in individual amounts. Each transaction is completed with two signatures, and one of the providers audits these accounts on a monthly basis. The resident or their representative are provided with a print out of the details of all expenditure whenever funds are topped up. Records in the home are generally well maintained and kept up to date. Some maintenance and servicing records were viewed, including lift servicing, gas, electricity, and fire alarm checks. Safe working practices are observed by ensuring that staff keep up to date with mandatory training. Care Homes for Older People Page 24 of 28 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 25 of 28 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 9 13 All handwritten entries on Medication Administration Records (MAR charts) must be signed by two staff. All controlled drugs must be stored in a controlled drugs cupboard, which meets the requirements of the Misuse of Drugs Safe Custody Regulations 1973. The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. 13/01/2009 2 16 22 The complaints procedure 31/01/2009 must be amended to include all relevant names, addresses and telephone numbers; and timescales for a response to complainants. The complaints procedure must be easily accessible to Care Homes for Older People Page 26 of 28 anyone visiting the home. The providers must ensure that a complaints log is maintained. The registered person must ensure that complainants receive a response with the outcome of their complaint within twenty eight days. The registered person must supply a summary of complaints and action taken, for the previous twelve months, to the Commission on request. 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 18 It is recommended that separate training is put into place in regards to the protection of vulnerable adults, so that the home can clearly demonstrate that all staff have had appropriate training. Care Homes for Older People Page 27 of 28 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). 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