Inspection on 01/12/08 for The Willows

This inspection was carried out on 1st December 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Willows 17/08/06

The Willows 09/02/06

The Willows 22/08/05

The Willows 30/03/05

The Willows 29/04/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Willows The Willows Field Terrace Ripley Derbyshire DE5 3HF     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: Jill Wells     Date: 0 1 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. 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. 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: The Willows Field Terrace The Willows Ripley Derbyshire DE5 3HF 01629531902 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Derbyshire County Council Name of registered manager (if applicable) Jeanette Mary Gilmour Type of registration: Number of places registered: 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 Willows Care Home is situated within the community of Ripley, located near to the town centre and the local Community Hospital. The Home has places for 20 older people. Two rooms are used for respite care. All bedrooms are for single occupancy and are situated on the ground and first floor of the Home. There is a passenger lift to the first floor. There are no en suite facilities. The Home has a 3 lounge areas, one being used as a lounge/dining room. Fees are #364 per week for permanent service users, with a range of prices for short term care service users. Additional charges are made for hairdressing, chiropody, newspapers and toiletries. 0 Over 65 20 care home 20 Care Homes for Older People Page 4 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for the service is two star. This means the people who use the service experience good quality outcomes. The inspection visit was unannounced and took place over 8 hours. There were 19 people living or staying at the home on the day of the inspection. 7 residents, 3 staff, 2 visitors, a visiting district nurse and the manager and deputy managers were spoken with during the visit. Some residents were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. We also looked at all the information that we have received, or asked for, since the last key inspection Care Homes for Older People Page 5 of 30 on the 17 August 2006. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection report. Completed surveys from people living at the home, staff, relatives and professionals that visit. Records were examined, including care records, staff records, maintenance, and health and safety records. A tour of the building was carried out. What the care home does well: What has improved since the last inspection? What they could do better: There was not information in peoples files concerning their past life. This would help staff to provide care in a sensitive way, taking into account their achievements and disappointments, hobbies and interests. Although activities were taking place, these were not always on a daily basis. Staff said that this was due to pressures on them and other tasks for example washing and ironing. Falls risk assessments were not been completed, however there was evidence that action was taken to minimise risk of falls to individuals, for example hip protectors. Several residents, staff and relatives commented about the staffing levels, believing that more staff were required to meet peoples needs. One resident said in our survey, more staff are needed to provide all the help we need. At the time of the inspection visit, dependency levels of people at the home were fairly low. If these levels increased, additional staffing would likely be needed. Staff rotas showed that there were several times throughout the day and particularly on Sunday when there was only one care assistant and the deputy manager on duty for short periods. Care Homes for Older People Page 7 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 8 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 9 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are fully assessed prior to admission so the individual and the home can be sure the placement is appropriate. Evidence: The annual quality assurance assessment completed by the manager said that brochures were given to prospective residents and their families on their initial visit. Reviews were carried out after six weeks to see if the resident has made the correct choice and their needs are being met. There was information about the service available for people. This included a statement of purpose that was available in the entrance hall and lounge areas as well as a service user guide also available in peoples bedrooms. These documents had recently been reviewed and amended. Further slight amendments were needed to ensure that they were followed up to date. For example they stated that there was a Church of England and a Salvation Army service, however the Church of England Care Homes for Older People Page 10 of 30 Evidence: service no longer takes place. It also states that the home is inspected by the Commission for Social Care Inspection at least twice a year. Although inspections still take place, these are no longer twice a year as the last inspection was August 2006. Three peoples records were seen. Each person had their needs assessed by a Social Services care manager before being admitted to the service. People were invited to visit the home and to move in on a trial basis before they made the decision to stay. Staff spoken with described how they settled new people into the home by trying to spend time with them, showing them around, introducing them to other residents and generally giving reassurance. Care Homes for Older People Page 11 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. Peoples health and personal care needs are met and the principles of respect, dignity and privacy are put into practice. Evidence: The annual quality assurance assessment completed by the manager said that following admission a personal service plan is drawn up with the resident to identify all their needs. A copy is given to the resident and the link worker reads the plan to the resident to ensure that it is accurate. It also said that the home respects residents wishes on end of life care and palliative care is carried out at the home whenever possible with guidance from relevant health professionals. The care records of three people living at the home were seen. Care plans had been completed by a social services care manager and staff from the home then completed a personal service plan. The personal service plans were written in a person centred way promoting independence for example one said, may need encouraging to have drinks as sometimes thinks they have just had one and another one said, can wash upper body at the sink with verbal prompts. One persons records that were seen who had Care Homes for Older People Page 12 of 30 Evidence: been at the home for two weeks for respite care did not have a personal service plan in place, however there was a fairly detailed care plan completed by the care manager. Records did not include information about peoples past life, which would have been helpful for staff when providing care and support. Peoples plans were written in plain language, and were easy to understand. They had been signed by the person, who was then given a copy. Information from surveys that were received from relatives and people living at the home was that care plans were not always fully followed by staff due to inadequate staffing. No additional information was received concerning this during the inspection visit but the matter was discussed with the acting manager. She believed that care plans were being followed but agreed to discuss this with individuals at their reviews. Individual records also included personal handling plans, nutritional assessment and tissue viability risk trigger tools. These were being regularly reviewed. Staff were not completing falls risk assessments. Records were seen of one person who had several recent falls. Although written falls risk assessments and plans were not in place, the person was wearing hip protectors to reduce the risk of injury. There was an inventory form to record items that new people had brought to the home, however two out of the three of these forms were blank. The manager said that these two people did not bring any significant items into the home, however the form did not explain this. Records, staff and people living at the home were all able to confirm that GPs and other health professionals were contacted and visited when required. A district nurse was spoken with during the inspection visit. They said that they were contacted when appropriate and felt that it was a very good home, with friendly staff, which had a positive effect on residents. They also commented that the home was always clean. Medication in the home was stored securely, however the temperature of the storage room was higher than the required temperature. The manager agreed to monitor this. Either the manager or deputy manager administered medication. All had received medication training. The medication administration records were seen and were correctly completed. Controlled drugs were securely stored and the controlled drugs register was checked and found to be accurate. There was a locked fridge for medication that required refrigeration. Care records showed that individuals had been assessed or asked if they were able to self medicate. People spoken with said that were treated with respect by staff. Care staff spoken with were very aware of the importance of respecting peoples privacy and could give examples of how they did this. One person said that, staff will always knock before they come into my room. Staff were observed having fun with residents whilst also being respectful. Care Homes for Older People Page 13 of 30 Care Homes for Older People Page 14 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. The range of activities and standard of meals offered was satisfactory, which generally met the needs and wishes of people living at the home. Evidence: The annual quality assurance assessment stated that people at the home are given the opportunity to develop interests, rekindle old skills and develop new ones. They have a choice in the activities they wish to take part in and activities take into account peoples capabilities. There were two staff providing 10 hours of activities per week. Other care staff were also expected to organise at least one activity per day. The planned activity for each day was recorded on a board in the home. Records were kept of activities that had taken place. These included food tasting, dominoes, PAT dog, crafts, and film nights with sherry and popcorn. The activities record book had several gaps where no activities were recorded. The manager said that they thought activities had taken place but had not been recorded by staff. However staff spoken with said that there was not always time for the activities. A visitor spoken with said that they had seen various activities including dominoes, bingo and kerplunk game. There was a monthly trip out. One resident spoken with said that they very much enjoyed recent trips to Bakewell and Mcarthur Glen shopping centre. One other person commented in Care Homes for Older People Page 15 of 30 Evidence: our survey, I enjoyed two outings this year, it was nice to get out in the fresh air and see different things and people. Another person commented, I wish we could get out more, it gets very boring. Individuals records did not include peoples interests and hobbies and activities that they would like to take part in. Although there had been a residents meeting just before the inspection visit, there had not been a meeting before that for 9 months. The manager explained that this was due to a shortage of managers at the time. Minutes of the recent residents meetings showed that people were being offered the opportunity to attend 2 weekly events held locally, the friendly circle and coffee morning. The manager told us that peoples religious needs were met with a regular Salvation Army service. The Church of England service had recently stopped due to the age of the parishioners. Staff told us that residents could go to bed and get up when they wished to do so. Staff meeting minutes showed that the manager had recently reminded them that residents can go to bed when they want and must not be pressured. Staff said that people were encouraged to eat in the dining rooms but if they were poorly or insisted they have a meal in their bedroom, then this was arranged. People were encouraged to bring their own personal possessions with them and bedrooms that were seen were comfortable and had been personalised. There was a menu displayed at the home. The cook and several residents confirmed that the cook spoke with each person in the morning to ask if they were happy with the main menu, or if they would prefer an alternative. On the day of the inspection visit one person had requested steamed fish rather than battered fish and this was provided. Another person had requested sandwiches. Residents spoken with were generally satisfied with the food. One person said, all the meals are good. Another person said, the meals are up and down, but mainly up. Several comments were made in surveys about the food provided. A staff member commented that residents may like butter rather than margarine and chicken breast rather than drumsticks. A relative was concerned about the food budget as they understood that this was less than 3 pounds per person per day. This was discussed with the manager who confirmed that the information was correct and was a standard figure across all Derbyshire County Council care homes. Her view was that as they could buy in bulk, keeping within this budget was not difficult to achieve whilst providing good-quality food. She also confirmed that butter was provided and some residents had requested chicken drumsticks. Mealtimes were observed and seen to be unhurried with vegetables in serving dishes to promote independence. Staff asked people if any assistance was needed. Care Homes for Older People Page 16 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. People who use the service are encouraged to express their concerns and are protected from abuse. Evidence: The annual quality assurance assessment completed by the manager stated that the home implements the Derbyshire County Council complaints policy and procedure. Anyone that has complained is informed about the timescales and progress of their complaints. The home has an open door policy where residents, visitors and staff can approach the management team with any issues. An advocacy services available to residents who wish to use this. There were 10 complaints recorded at the home since the last inspection visit. These were generally low level complaints, some from residents about other residents. These records showed that managers took all complaints seriously and took action to satisfy the complainant. The complaints procedure was displayed at the entrance as well as other areas around the home. It was worded in such a way to encourage complaints starting with, please do not be afraid to complain, it is your right. It also included the name, address and telephone number of the Commission for Social Care Inspection (CSCI). People spoken with said that they would talk to staff or the manager if they had a complaint and felt confident that they would be listened to. Training records showed that care staff had attended training in safeguarding vulnerable adults and care staff confirmed that they had attended this training and Care Homes for Older People Page 17 of 30 Evidence: were aware what to do if they suspected abuse of a vulnerable adult. They were aware of the policy concerning whistle blowing in order to protect vulnerable people. Care Homes for Older People Page 18 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, well-maintained and comfortable environment, which encourages independence. Evidence: The annual quality assurance assessment completed by the manager stated that they maintain a clean, safe, homely environment and have the correct specialist equipment to meet peoples needs. Residents take an active part by choosing soft furnishings and how they would like their bedrooms decorated. The garden is planted each year with hanging baskets and a range of seating areas is provided. Local Brownies are involved each spring with pot planting. The summer house has been refurbished this year. The home is a purpose-built home set within large gardens. There are 20 single rooms, all with a wash hand basin. A tour of the building showed that the home was clean and well maintained. People spoken with said that they were happy with the level of cleanliness at the home. One resident said, its always clean. One person commented that, it would be perfect if we all had our own toilet. Information from the service was that the whole home had been decorated since the last inspection visit. There were two bathrooms and a shower facility. There were several toilets on each floor, although they were some distance from the main lounge area for anybody with mobility difficulties. There were grab rails and other aids around the home to assist people and maximise their independence. A relative spoken with said that as it was a Care Homes for Older People Page 19 of 30 Evidence: smaller home it was more homely and people dont get lost so easily. They also commented that, its a lovely garden and nice to walk out There was adequate storage areas to ensure that equipment etc was stored safely. Laundry facilities were sited away from the main areas where food was stored and prepared. Laundry had industrial washers with sluicing facility and an industrial dryer. People spoken with were satisfied with the laundry service, although there had been recent problems with staff putting clothing on a boil wash, but this has since been resolved. Bedrooms that were seen were comfortable and homely. People had personalised their own room. One person said that, my room is very nice and the bed is comfy. There was a public telephone available for people living at the home to use, however at the time of the inspection visit this was out of order and due to be repaired. As a result of comments from staff at a staff meeting the fencing and gate had been replaced. As a result of a service manager visiting and observing fascia boards in poor condition, these had been quickly replaced. A previous inspector had highlighted poor lighting in some areas, and these areas now had improved lighting. This is evidence that the manager was quick to respond to maintenance and refurbishment issues. Care Homes for Older People Page 20 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. The recruitment practices and staff training programme were good and ensured that people were protected by competent, well-trained staff. The staffing levels may not meet the needs of people at busy times. Evidence: The annual quality assurance assessment completed by the manager stated that staff received excellent induction training and ongoing training for established staff. The home has the correct allocation of staff to meet residents needs. A link work system is in place that helps form good relationships between staff and residents and bonds are formed. It also stated that the home follows Derbyshire County Councils recruitment and selection policy to ensure that appropriate staff are employed following all relevant checks. On the day of the inspection visit there was the manager, deputy manager and 2 care assistants on duty, as well as the cook and kitchen assistant. The duty rota showed that there was always a manager or deputy on duty during the day and 2 care assistants on at all times. However on close examination of the rotas it showed that there was regularly a 30 minute gap when there was only one care assistant on duty in the morning, and a 15 minute gap at the start and end of the afternoon shift. There was also a one hour gap on Sunday between 3 p.m. and 4 p.m. when there was only Care Homes for Older People Page 21 of 30 Evidence: one care assistant on duty. The manager explained that the manager on duty would cover the care hours during these periods. She stated that these gaps were due to only having an allocated number of hours by the Department. She also explained that she had been told to include all of the deputy hours as care hours when making care staff hours calculations. However it was evident that the deputy managers had significant administrative work to do which meant that all of their hours could not be counted as care hours. She thought that the 2 deputy managers on each day undertook on average three hours care duties. One resident wrote in our survey in response to the question concerning staff availability when needed, the staff always seemed to be very busy, more staff are needed. Another resident said, more staff are needed to provide all the help we need. A staff member wrote on our survey, there should be more staff to give more time to people with dementia. A visitor wrote in our survey Mum needs a lot of care, she is nearly always wet when I visit. She needs taking to the toilet and changing often and there doesnt seem to be enough staff to do this. A member of staff said that, we have so many extra duties like washing and ironing it can be difficult to spend enough time caring for residents. The manager gave the dependency levels of people at the home at the time of the inspection visit as 14 people with low needs, 5 people with medium needs and no one with high needs. Information received after the inspection visit was that agreement has been made to provide additional care, laundry and administration hours in the near future. It was evident from discussions and observation that staff worked very well as a team. Several positive comments were received from residents about staff. These included, its very nice living here, staff will do all they can do and, the staff are brilliant and the cleanliness is second to none. Another person said, staff come in with a cup of tea in the morning and ask if I need any help, I feel safe and looked after. From discussions with staff it was evident that they were experienced and sensitive to peoples needs. One worker described how important it was to greet people in a friendly manner and make sure that they have a positive attitude. Another staff member explained how important it was to reassure the person if they were embarrassed about the personal care that they needed. Domestic staff were employed in sufficient numbers to ensure that the home is maintained in a clean and hygienic state. Two staff records were seen. Copies of application forms and references were in place, however other checks for example criminal record bureau checks were held centrally and not available at the inspection visit. Care Homes for Older People Page 22 of 30 Evidence: There was an induction programme in place that met the Skills for Care standards and included first aid, food hygiene, moving and handling, hoist training, dementia care, safeguarding adults and bereavement. Information received was that staff turnover was low with only two staff leaving in the last 12 months. The manager described a well-developed training programme, with training records to support this. Although not all mandatory training was up-to-date, the manager confirmed that several courses were planned in the near future. The planned courses included infection control, promotion of continence, tissue viability, end of life care and sensory impairment. Staff had achieved above the minimum requirement of 50 percent care staff with National Vocational Qualification, (NVQ), at level 2 or 3. Care Homes for Older People Page 23 of 30 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is very well managed, with quality assurance systems, ensuring that people are listened to and the home continues to develop and improve. Evidence: At the time of the inspection visit there was an acting manager at the home. They had been a deputy manager for a number of years and were proving to be an effective manager, creating an open and inclusive atmosphere. The permanent manager had been recruited, but had not yet started in the post. Residents and staff spoken with felt that if they had any ideas or concerns they would be listened to by the managers working at the home. Questionnaires had been sent out to staff and residents in 2007, however there was still no analysis of the questionnaires from residents. The analysis of the questionnaires by staff showed that staff rated the building comfort, cleanliness, food Care Homes for Older People Page 24 of 30 Evidence: and activities highly. Staff suggested that the frequencies of offering baths needed improvement. The manager said that people were now offered more than one bath per week if they wished to have this. Each person had an annual review. During this meeting they were asked their views of the environment, care provided, meals, activities and outings. Any concerns or ideas highlighted during this discussion were acted upon. Resident and staff meetings had recently taken place and minutes of these meetings showed that people were given the opportunity to have their say. These meetings however were not taking place regularly. At the last staff meeting showed that the manager given clear guidance about changes to the fire evacuation system, reminders about fighting infection, good recording practice and confidentiality. One requirement and four recommendations were made at the last inspection visit and all had been complied with. The service manager responsible for the service was visiting regularly and was completing a monthly report. The report showed that time was spent with staff and residents and the environment and some records were checked at every visit. The system for the safekeeping of service users money was checked and found to be a safe and effective system. Record showed that staff supervision was taking place on a regular basis and staff confirmed this. Records were generally well maintained, up to date, accurate and kept securely. Staff confirmed that relevant equipment was in place to ensure safe working practices when assisting with moving someone including hoists, a stand aid and rotunda. Fire records were checked and found to be in good order. A fire risk assessment had been completed and reviewed. Fire drills were taking place and fire-fighting equipment was regularly serviced and checked. The manager completed a health and safety audit in 2008. The annual quality assurance assessment completed by the manager stated that all required servicing had taken place. A sample of these certificates was checked and the information provided was found to be accurate. Care Homes for Older People Page 25 of 30 Evidence: Accidents and injuries were recorded and reported. The manager was reviewing on monthly basis accidents that had occurred, to see if there were any patterns and took relevant action that was needed as a result of this. 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 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 should be further reviewed to ensure that all information is accurate and up-to-date for people living at the home. Information should be obtained and recorded in peoples files concerning their past life in order to assist staff to provide holistic and sensitive care and support. There should be written falls risk assessments for each person as well as care plans to identify action to be taken for anyone that may be at risk to ensure that steps have been taken to minimise peoples risks of falls. Peoples interests should be recorded to ensure that they are given opportunities for social stimulation that suits their needs. Activities that have been provided should be clearly recorded to show evidence of the activities that had been made available. Care hours should be calculated to take into account the number of administrative hours that the deputy managers undertake to ensure that the care hours calculations accurately reflect the care hours provided. 2 7 3 8 4 12 5 12 6 27 Care Homes for Older People Page 28 of 30 7 27 There should be a minimum of two care staff on duty at all times to ensure that there are sufficient care staff on duty to meet the needs of people living at the home. All relevant recruitment information and checks should be available during the inspection visit to allow the inspector to undertake their regulatory role. The plans training programme should continue to ensure that all staff have the required up to date mandatory training including refresher training. The analysis of the quality assurance questionnaires sent out to residents and staff, and action plan following this should be made available to relevant people in a more timely way. This is so that people can be made aware of the outcome of the system to seek peoples views. Residents and staff meetings should be held regularly to give people an opportunity to have their say about the home and the way that care is provided. 8 29 9 30 10 33 11 33 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. 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