Inspection on 08/10/09 for The Ridings

This inspection was carried out on 8th October 2009.

CQC found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Ridings 06/11/08

The Ridings 20/11/07

The Ridings 29/05/07

The Ridings 16/01/07

The Ridings 30/08/06

Extracts from inspection reports are licensed from CQC, this page was updated on 17/02/2010.

Key inspection report Care homes for older people Name: Address: The Ridings Farnborough Road Castle Vale Birmingham B35 7JG     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Lisa Evitts     Date: 0 8 1 0 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. 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 mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). 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 CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: The Ridings Farnborough Road Castle Vale Birmingham B35 7JG 01217488770 01217470163 theridings@dukerieshealthcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Dukeries Healthcare Name of registered manager (if applicable) Mr Kevin John Bradley Type of registration: Number of places registered: care home 82 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: The maximum number of service users who can be accommodated is: 82 The registered person may provide the following category of service only: Care Home with Nursing (Code N); To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 82 Date of last inspection Brief description of the care home The Ridings is a large care home in Castle Vale that is registered to provide care for 82 people with dementia care needs. There are two residential units called Aintree and Doncaster, two units which provide nursing care called Cheltenham and Ascot and two units for younger adults known as Champion Crescent. The bedrooms all have single en-suite facilities and are spread across six independent units. All units have their own dining room, lounge areas and bathing facilities. There Care Homes for Older People Page 4 of 28 Over 65 0 82 1 3 1 1 2 0 0 8 Brief description of the care home are fully adapted bathrooms and showers to meet peoples needs and additional toilets are available for wheelchair users. All areas of the home including the first and second floors are accessible by a large passenger lift. There are enclosed gardens for people on all units to access. There are disabled parking spaces and limited car parking at the front of the building with additional car parking behind the home. The home is close to bus and rail routes in and out of the city and is within close proximity of local shops and other community facilities such as a retail park. On the day of this visit fee rates for living at the home ranged between £570 - £1080 per week depending on individual needs assessments. These rates are reviewed annually and the home should be contacted for current rates. There are a number of noticeboards which supply information about the home and the last inspection report is on display for people to read if they choose to. Care Homes for Older People Page 5 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 focus of our inspections is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provisions that need further development. Two inspectors undertook the fieldwork visit to the home over nine and a half hours. There were 78 people living at the home on the day of the visit, two of these people were receiving care at the hospital. The home did not know that We, the commission were visiting that day. One inspector completed a Short Observational Framework for Inspection (SOFI). Because people with dementia are not always able to tell us about their experiences, we use a formal way to observe people to help us understand. The SOFI involved us observing up to five people who use the services for two hours and recording their Care Homes for Older People Page 6 of 28 experiences at regular intervals. This included their state of well being, how they interacted with staff members, other people who use the service and the environment. The results of this observation are included within the report. Information was gathered from speaking to and observing people who lived at the home. Three people were case tracked and this involves discovering their experiences of living at the home by meeting or observing them, looking at medication and care files and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. We also looked partly at two further files. Staff files, training records and health and safety files were also reviewed. Before the visit we sent random surveys to fourteen people who live at the home and ten staff. We received ten completed surveys from people who live at the home and two from staff. One relative and four staff were spoken to. Prior to the inspection the manager had completed the Annual Quality Assurance Assessment (AQAA) and returned it to us. This gave us some information about how well the home think they are performing. It tells us about the home, staff and people who live there, what the home do well and what they need to improve. Before the visit we reviewed any notifications received about the home. These are reports about things that have happened in the home that they must tell us about. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 8 of 28 following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 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 10 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. Arrangements are in place to ensure that people have the information they need and can be confident their needs will be met if they decide to live at the home. Evidence: The service users guide is available in each persons bedroom and the statement of purpose is displayed in reception. The documents can be made available in large print upon request. The home are initiating audio and video versions so that people with visual impairments can access this information. Both of the documents had been reviewed in April 2009 to ensure that they had current and detailed information about the home. This means that people can make an informed decison about whether they may want to live at the home. Fee rates are also included so that people know how much they will have to pay to live there. The certificate of registration was clearly displayed in the reception area and a copy of the previous inspection report is available so that people have access to this Care Homes for Older People Page 11 of 28 Evidence: information if they want to read it. People have an individual contract that states what room they will move in to and tells them how much it will cost to live there. A trial period is offered so that people can be sure it is where they want to live. Before anyone comes to live at the home, comprehensive pre admission assessments are undertaken so that the person and the home know that their individual needs can be met before they move in. The AQAA told us that people are encouraged to visit the home before they move in so that they can see what it is like. On the day of our visit we saw that some relatives had come to look around and were shown around the home by one of the staff. Care Homes for Older People Page 12 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. The personal care and health needs of the people living there are met so ensuring their well being. Evidence: Each person has a written care plan. This is an individualised plan about what the person is able to do independently and states what assistance is required from staff in order for the person to meet their needs. We looked at three peoples care files in detail and reviewed two further plans for specific needs of individuals. The AQAA told us that the home was re writing the care plans in a phased manner so that they were more personalised. Care plans we looked at contained a lot of personal information about peoples needs and about their personal preferences. For example prefers male carer for bathing and shouts out loudly when in pain. Plans gave good information for staff to follow when people showed difficult behaviours. For example one plan had identified that a person could use inappropriate language and appear threatening. Staff had identified that this was generally on waking and gave staff guidelines to follow so that this behaviour could be minimised. Care Homes for Older People Page 13 of 28 Evidence: Plans for care of wounds were very detailed and had been updated with recommendations from the specialist tissue viability nurse. There was evidence that the dressings for one person had recently been changed. These had been delivered to the home on the day of our visit which means that staff act upon recommendations from external professionals so that people receive the most appropriate care. One wound assessment chart had not been completed when the dressings had been changed. The tissue viability nurse visit had not been entered into the multi disciplinary visit record. This would make it easier to track when people had been seen by external professionals. Risk assessments were in place for moving and handling and gave staff instructions about how to move people if they should fall. Risk assessments were also completed for falls, nutrition and skin soreness. People had individual risk assessments for identified needs such as the need for one to one staff when out in the community and this was observed to be followed on the day of our visit. People were weighed monthly or weekly if they were at risk from weight loss. This will mean that staff can monitor any changes and refer to other external professionals if further guidance is required. People were supported by staff and were well presented. During the SOFI and throughout the day, staff were observed to treat people with respect and maintain their dignity. During the SOFI we saw only one negative interaction, when a member of staff was quite loud vocally whilst interacting with someone who lived at the home. We brought this to the managers attention on the day of the visit. One persons file stated that they like to wear a T shirt and jeans. A plan written told staff to ensure that the person wore clothing that would make it difficult for them to remove their clothes, to minimise the possibility of them urinating in inappropraite places. The plan stated this would include jeans and a secure belt. The person was wearing jogging bottoms so we could not evidence that the care plan had been followed and this was discussed with the manager. A relative told us The staff know mom well, she is always washed and cleaned. In the surveys returned to us five people said they always receive the care and support they needed, four people said usually and one person said sometimes. One person told us that the manager had organised a support for the wheelchair so that they could take their relative out safely. We looked at the management of medication and looked at records for six people. Copies of prescriptions were kept so that staff could check they had received the Care Homes for Older People Page 14 of 28 Evidence: correct medication into the home. Medication was signed in when received. Room and fridge temperatures were recorded to ensure that medication was stored at the right temperature. There were no Controlled drugs in use on the units that we looked at. All of the audits we looked at were correct with the exception of one person who had been given the wrong dose of a tablet at the wrong time of day. It was concerning that the nurse knew about the error but had not taken any action. At the last inspection a requirement had been made about the management of medication and due to this we discussed our findings with the Regional Enforcement Team. The home have since told us that the GP had been contacted and staff were receiving supervision to prevent this error occuring again. The home completes an audit each week and it is likely that this error would have been found. We have decided not to take further action at this time but our pharmacy inspector has completed a inspection at the home to monitor the homes management of medication and to ensure that people receive their medication as prescribed. Care Homes for Older People Page 15 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. People have a choice of activities so that they experience a meaningful lifestyle. There is a choice of meals to meet peoples dietary needs or personal preferences. Evidence: The home has two dedicated activity coordinators. There are a range of activities offered to people including board games, coffee mornings, aromatherapy, arts and crafts, audio books and films. A hairdresser visits the home once a week so that people can have their hair styled in a way that they prefer. A church service is held once a week so that people can continue to follow their religion if they choose to. People go out shopping and visit the local stables to see the horses. People were seen to go out with staff into the garden and shopping during our visit and one person went out with their family for the afternoon. A poster was displayed advertising an external entertainer who was a vocalist and guitarist. This should mean that people participate in things which are meaningful to them. People living on Champion Crescent are encouraged to go out into the local community as part of their rehabilitation. This unit has a kitchen; laundry and utility area where people are encouraged to participate in these activities. We saw that people had hung out their washing on the rotary line in the garden and we observed Care Homes for Older People Page 16 of 28 Evidence: one person washing cups at the sink. During the Short Observational Framework for Inspection (SOFI) we saw people looking at picture cards, staff reading newspapers with people and playing with sensory toys. Some people were watching TV and some were listening to music. On Cheltenham unit the overall score showed positive staff interactions of 89 with the remaining 11 being neutral. On Ascot unit the overall score showed 79 positive, 17 neutral and 4 negative staff interactions. People were mostly in a passive state of being. One relative told us that the manager had arranged for a neck support for their mom so that they could take her out safely in the wheelchair. This means that this person was able to receive stimulation by going outside of the home with their family. There is an open visiting policy, which means that people can see their friends and relatives as they choose and can continue with relationships that are meaningful to them. There is a four weekly rolling menu and these showed choices of meals. The menu currently offers two hot choices at lunchtime and a hot choice or soup and sandwiches in the evening. Salads, fresh fruit, and ice cream are available on request. A roast meal is offered on a Sunday and a full English breakfast is available if chosen. We observed people to have a full breakfast on the morning of our visit. Staff were observed to assist people who needed help and encourage them to eat their meals in a dignified manner. A relative said the staff feed mom on a pureed diet, as she is unable to feed herself. Care Homes for Older People Page 17 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. People can be confident that their views are listened to and acted on. Arrangements should ensure people are safeguarded from harm. Evidence: The complaints procedure is on display in reception and is included in the service users guide in each persons room, making it accessible to people if they want to make a complaint. Since the last inspection we have received two complaints which we have asked the provider to investigate using their complaints procedure. The AQAA told us that the home have received 28 complaints in the last year. We sampled the complaints records. There was clear documentation about the nature of the complaint, how it had been investigated and the outcome. Outcome letters are sent to the person who has complained so that people know that they have had their concerns listened to and acted upon. In the surveys people returned to us they told us that they knew who to speak to if they were unhappy. A relative told us If I had a problem I would raise it with them. This means that people know what to do if they have any concerns. The manager has an open door policy so that people can see him at anytime to discuss any concerns they may have. The home has a copy of the local Multi Agency Guidelines and an adult protection Care Homes for Older People Page 18 of 28 Evidence: policy. This should ensure that staff have guidelines to follow in the event of any allegations of abuse. The home currently have five safeguarding cases open and are proactive in making referrals to social services to ensure that people are safe from harm. Staff had received training in safeguarding so that they have up to date knowledge about what they should do to keep people safe. Staff spoken to were able to give good responses to questions about how to keep people safe. Some staff have received training in the Deprivation Of Liberties Safeguarding. This act governs decision making on behalf of adults and applies when people lose mental capacity at some point in their lives or when they have had an incapacitating condition since birth. The home had made two referrals under this act to ensure that people were safe whilst not depriving them of their liberty.The manager has a good understanding of this and persues referrals in peoples best interests. Care Homes for Older People Page 19 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. People are provided with a clean and comfortable environment in which to live that meets their individual needs. Evidence: There are six different units within the home and each unit is decorated in a style relevant to the people who live there. Each unit has its own dining area and communal lounge however people can spend time on different units if they prefer to. There was a good atmosphere throughout the home and staff were observed to take people around the home as they were completing tasks, for example one person came down to use the photocopier with a staff member. Corridors are wide and spacious and have pictures of interest and tactile pictures to stimulate people as they walk around the home. Some areas of the home had been redecorated and some areas needed redecoration. The AQAA told us that there was a redecoration programme in place and we were told about plans for new decorations and furnishings to make the home more homely and less clinical in places.The home had purchased equipment including mattreses and cushions to prevent skin becoming sore, new beds and chairs, new decorations for walls and pressure mats. (These alert staff if people get out of bed unassisted and may be at risk of harm). This will ensure that people have the equipment they are assessed as needing and that their needs are met. Care Homes for Older People Page 20 of 28 Evidence: Bedrooms seen were personalised as people had chosen and had items that were familiar to them to make their room as comfortable as possible. Rooms are painted in a variety of colours which people are able to choose. Some rooms have photographs on the doors to help people to identify which room is theirs. The home has an attractive garden area and people were seen to use this throughout the day accompanied by staff. A garden project has been started and there are plans to improve the garden further with sensory areas and fruit and vegetable plots which people from the home can be involved with if they have an interest in this. Care Homes for Older People Page 21 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. People are supported by staff who receive training to ensure that they have the knowledge to meet peoples needs. The recruitment procedure ensures that people are safeguarded from harm. Evidence: Each unit has its own staff rota so that it is clear who is working a shift. Rotas showed that shifts were covered when people were on leave or absent from work. In the morning there are 21 carers, 17 in the afternoon and 13 at night. There are three trained nurses on duty at all times. In addition to the nursing and care staff the home also employs domestic, laundry, administration and maintenance staff to meet all the needs of the people who live there. Since our last visit the staffing group has become more stable and the home no longer have to use agency staff. This means that people know who will be assisting them to meet their needs. During the late afternoon we observed that staff were not always available to meet peoples needs, on one unit. Two staff were in a room assisting a person and there was no one else on the unit to assist a person who was calling out. This was brought to the attention of the manager at the time and staffing levels on this unit should be reviewed to ensure that peoples needs can be met. During the Short Observational Framework for Inspection (SOFI) Staff were observed Care Homes for Older People Page 22 of 28 Evidence: to interact well with people who live at the home and there was a pleasant atmosphere. Staff were observed to encourage people to do things for themselves to maintain their independence. People were told by staff what they were doing for example when they were being hoisted into a chair. People were given choices about drinks. One person was asked if they wanted to go to bed, and when they declined, staff fetched a pillow to make them more comfortable. 70 of staff have completed a National Vocational Qualification (NVQ) Level 2 in care.This is above the national minimum standards and should ensure that the staff have the knowledge and skills to care for people individually and collectively. We looked at three staff files and these contained all the required information to ensure that people were safe from harm. Staff complete a basic induction into the home which is then followed by a more detailed 12 week induction. A member of staff told us I had an induction, I was shown paperwork and told about peoples needs, and I had moving and handling training before I could do anything.This should mean that staff are knowledgeable about their role. The home has a training matrix, which is updated with the training that staff have undertaken to increase their knowledge and skills.The home has E Learning courses where staff can complete the training at their own pace.Training includes protection of vulnerable adults, moving and handling, infection control, dementia, fire, emergency first aid, medication and Control Of Substances Hazardous to Health (COSHH). Care Homes for Older People Page 23 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 in the best interests of the people who live there. Evidence: The manager has been at the home for approximately one year and is now registered with us. The manager is a Registered Mental Nurse and has experience within management roles and demonstrates a commitment to continually improve the home for the people who live there. The manager has a good knowledge of the people who live at the home and their needs. Relatives and staff said: He is approachable The manager sorts things out I believe in him, the home is stable now Resident and relative meetings are held and the minutes from these were available in Care Homes for Older People Page 24 of 28 Evidence: reception. One relative said they they were unable to attend the meetings due to the times they were held but they always had a copy of the minutes to read. These meetings enable people to voice any concerns or raise ideas about how the home could improve. A meeting has been held with relatives to discuss setting up a relatives committee and a further meeting is planned to discuss this in more detail.The manager hopes that people who live at the home and their relatives will become more involved in the running of the home by being included in recruitment, meal planning and quality of the service. Progress with this will be reviewed at our next visit to the home. External managers visit the home and write a monthly report about the quality of service provided. The home also complete audits and customer satisfaction questionnaires so that information about how well the home is performing is collected. Prior to the inspection the registered manager had completed the Annual Quality Assurance Assessment. This gave us detailed information about how the home thought they were performing, what they do well and how they could improve. The manager had identified areas where improvements could be made and had plans in place as to how to achieve this. The information in the AQAA was consistent with our findings on the day of our visit. The home is able to hold small amounts of personal money for people. Each person has an individual record and receipts are kept which matched the entries made. With the exception of one minor discrepancy we found that audits were correct. The home also audit the money and it was not clear why the discrepancy had not been identified. This was brought to the attention of the manager on the day of our visit. Records of servicing, tests and maintenance in respect of health and safety for utilities, equipment and appliances are well maintained and should ensure that they are safe to use. Accident and incidents are well recorded and a monthly analysis ensures that any trends are identified and acted upon. Training records showed that 68 percent of staff had completed fire training. Records showed there had been one fire drill at the home and this does not ensure that all staff take part in fire drills to ensure that they know what to do in the event of a fire. Staff spoken to confirmed that they had taken part in a drill when they completed the fire training. The home must ensure that all staff take part in fire drills and that records show this. We saw that some bedroom doors on Doncaster unit had been propped open with chairs during the afternoon and this was brought to the managers attention at the time as this does not ensure peoples safety in the event of a fire. Care Homes for Older People Page 25 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 26 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 38 23 All staff should participate in 11/12/2009 fire drills. To ensure that they know how to protect people from harm in the event of a fire. 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 2 7 27 Records should provide a clear audit trail so that information is easy to retrieve. Staff should be available to meet peoples needs at all times. Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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. 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