Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 08/12/08 for The Willows Nursing Home

Also see our care home review for The Willows Nursing Home for more information

This inspection was carried out on 8th 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People we spoke with said "we`re well looked after here". One relative said, "The care home is excellent", and another said, "My Mum is very happy at The Willows". People we spoke with said the staff were "all very nice". Relatives told us the staff "show that they really care about the service users", "staff are very professional and caring", "they make my Mum laugh", and "I have never seen or heard any comments that are inappropriate". We observed that staff had a positive approach and good rapport with people in the home. There was a good programme of staff training and all the required training was up to date. Staff had received training about the needs of people with dementia and about equality and diversity. 50% of care staff had achieved a National Vocational Qualification (NVQ) Level 2 or above in care.

What has improved since the last inspection?

The two requirements made at the previous inspection in December 2007 had been met, resulting in improvements to care plans and manual handling procedures. The home was developing a themed lounge / dining room in the dementia care unit to promote reminiscence. They had some suitable furniture and objects in place and were asking relatives and visitors to donate appropriate items. The home also planned to create a `sensory` room in the dementia care unit.

What the care home could do better:

Some care plans were reviewed more regularly than others. There should be a consistent approach to the review of care plans and risk assessments so that they are up to date and reflect the changing needs of the person. Care plans should be reviewed at least monthly, or whenever there is a significant change in the person`s condition or circumstances. Some improvements could be made to the system for the safe handling and administration of medication to ensure a robust system that protects people in the home. Staffing levels should be increased to ensure there are always a total of six care assistants working the morning and afternoon shifts. This will help to ensure people`s needs are consistently met. Improvements should be made to the home, particularly to the bathrooms, to ensure a safe and pleasant environment for people living there.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: The Willows Nursing Home 7 Norbriggs Road Woodthorpe Mastin Moor Chesterfield Derbyshire S43 3BW     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: Rose Moffatt     Date: 0 8 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 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 Nursing Home Woodthorpe 7 Norbriggs Road Mastin Moor Chesterfield Derbyshire S43 3BW 01246280539 01246280799 the.willows@craegmoor.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Parkcare Homes Ltd Type of registration: Number of places registered: care home 41 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Parkcare Homes Limited 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: Old age, not falling within any other category - code OP (maximum number of places 22) Dementia - Code DE (maximum number of places 19) The maximum number of service users who can be accommodated is 41 Date of last inspection Brief description of the care home The Willows is located in the village of Woodthorpe, near to Staveley where there are amenities including a supermarket, church, post office and library. The home provides accommodation in single rooms, some of which are en suite. There is a dining room, Care Homes for Older People Page 4 of 30 Over 65 0 22 19 0 Brief description of the care home lounge and conservatory on the ground floor and two dining / lounges on the first floor. There is access to the enclosed garden and car parking space is provided to the front of the building. The Willows provides personal and nursing care for up to 41 people, including a maximum of 19 people whose primary care needs are due to dementia. The fees range from £355.52 to £910.89 per week, depending on individual needs. This information was provided by the acting manager on 8th December 2008. Information about the home, including CSCI inspection reports, is available in the main entrance area of the home or from the acting manager. Care Homes for Older People Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 star. This means the people who use the service experience good quality outcomes. The focus of our inspection is on outcomes for people who live in the home and their views on the service provided. The inspection process looks at the providers ability to meet regulatory requirements and national minimum standards. Our inspections also focus on aspects of the service that need further development. We looked at all the information we have received, or asked for, since the last key inspection or annual service review. This included: the annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment Care Homes for Older People Page 6 of 30 that focuses on how well outcomes are being met for people using the service. It also has some numerical information about the service; surveys returned to us by people using the service and from other people with an interest in the service; information we have about how the service has managed any complaints; what the service has told us about things that have happened - these are called notifications and are a legal requirement; the previous key inspection and the results of any other visits we have made to the service in the last 12 months; relevant information from other organisations; and what other people have told us about the service. The last key inspection of the home was on 12th December 2007. We carried out an unannounced inspection visit that took place over seven hours on 8th December 2008. The inspection visit focused on assessing compliance with requirements made at the previous inspection and assessing all the key standards. We sent out 10 surveys to people living in the home and received 2 completed responses. We sent out 10 surveys to the relatives or representatives of people living in the home and received 4 completed responses. We sent out 10 surveys to staff employed at the home and received 6 completed responses. There were 36 people accommodated in the home on the day of the inspection visit. People who live in the home and staff were spoken with during the visit. The acting manager was available and helpful throughout the inspection visit. Some people 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. Case tracking was used during the inspection visit to look at the quality of care received by people living in the home. Four people were selected and the quality of the care they received was assessed by speaking to them, observation, reading their records, and talking to staff. 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 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 Care Homes for Older People Page 8 of 30 printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a thorough assessment process so that people were confident their needs could be met at the home. Evidence: We received completed surveys from two people in the home. Both people said they had received enough information about the home so they could decide if it was the right place for them. Both people said they always received the care and support they needed. We received completed surveys from four relatives of people in the home. Two people said the home always met the needs of the person, two said the home usually did. One relative said, The care home is excellent, and another said, My Mum is very happy at The Willows. Care Homes for Older People Page 11 of 30 Evidence: We received six completed surveys from staff in the home. Four said they always had up to date information about the needs of people in the home, one said they usually did, and one did not respond. All six said they had training to help them understand and meet the individual needs of people in the home. The training records showed that staff had received a range of training, including training about the needs of people with dementia and training about equality and diversity. Staff spoken with confirmed they had received this training. We looked at the care records of four people in the home. Each had assessments of the persons needs, including assessments by hospital and social services staff and by staff from the home. The assessments covered all areas of the persons life and included their needs and preferences. Each person had a care plan produced from the assessment information. Standard 6 did not apply as there were no people receiving intermediate care. Care Homes for Older People Page 12 of 30 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were satisfactory care plans and a good staff training programme so that people had care and support in the way they required and preferred. Evidence: Two people who returned our surveys said they always had the care and support they needed, including medical support. People we spoke with said were well looked after here. They said that staff knew what their needs were. They confirmed that they could see their GP when they needed to, and that they had access to other health care services, such as the chiropodist and district nurse. Two relatives who returned our surveys said the home always met the persons needs and two said the home usually did. One relative said the staff show that they really care about the service users. Another relative said there is not always enough staff on to give the time my Mum needs to feed. Four of the staff who returned our surveys said they always had up to date information Care Homes for Older People Page 13 of 30 Evidence: about the needs of people in the home, one said they usually did, and one did not respond. All six said they had training to help them understand and meet the individual needs of people in the home. One of the staff who returned our survey said there were usually enough staff to meet peoples needs, two said there sometimes were, and two said there never were. Staff spoken with said staffing levels were not always sufficient to meet peoples needs - see Staffing section of this report. We looked at the records of four people in the home. Each person had a care plan that covered all of their assessed needs. The care plans had details of the action required by staff to meet individual needs. The care plans included details of the persons likes and dislikes, and personal preferences regarding care and routines. There were details of how staff should ensure the persons dignity and privacy. Two of the care plans seen had been reviewed monthly up to date. The other two had been reviewed, though not every month. At the last inspection in December 2007, we made a requirement that all people in the dementia care unit must have a specific care plan for their mental health needs. The four records we looked at each had a care plan for the persons mental health needs and so we found that this requirement had been met. Each of the care records included a range of assessments to ensure the persons health care needs were met. These included an assessment of the persons needs for moving and handling and any associated risks, an assessment of the risk of the person developing pressure sores, and an assessment of the persons nutritional needs. Three people had an assessment of their continence. There were assessments to ensure the persons safety including a falls risk assessment, an assessment of the persons ability to manage their own medication, and an assessment of the need to use bed rails. For two people, the assessments had been reviewed monthly up to date. For the other two people the assessments had been reviewed less often. There were records of the input of other health care professionals, such as GP, District Nurse and chiropodist. Two people had been regularly reviewed by a consultant psychiatrist. A relative said the person was always accompanied by a trained member of staff if she has to attend hospital. Medication was stored securely in the home and was administered by the qualified nurses. The records seen were mostly satisfactory. There were some handwritten instructions on administration records that had not been signed by the person who had written them or counter signed by another member of staff to ensure they were Care Homes for Older People Page 14 of 30 Evidence: correct. There were no details for medication prescribed as required to ensure staff knew when this medication should be given and any alternative action to try first. Records of the disposal of medication were checked and signed by one nurse. Two people who returned our surveys said the staff always listened to them and acted on what they said. People we spoke with said the staff were all very nice. Relatives told us that staff are very professional and caring, they make my Mum laugh, and I have never seen or heard any comments that are inappropriate. We observed that staff had a positive approach and good rapport with people in the home. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a satisfactory range of activities offered and peoples choices were respected so that the lifestyle in the home generally met their needs and expectations. Evidence: One person who returned our survey said there were always enough activities arranged by the home, one person said there sometimes were and commented could do with more. One relative who returned our survey said the home could improve by staff having more time to talk and do things with people in the home. Another relative said there are not many activities arranged at the home, and, the Christmas period is busy with lots of things going on at the home but this needs to be kept up all year. We spoke with people in the ground floor lounge who said there were not always enough activities offered. We observed that there were activities planned and happening in the dementia care unit. There were activities staff employed at the home. We looked at records of activities offered to people in the dementia care unit. There was a range of activities, such as Care Homes for Older People Page 16 of 30 Evidence: games, music, and a regular film night. People had made Christmas decorations and there was a visiting entertainer on the day of the inspection visit. There was a regular church service held in the home. The home planned to have a sensory room within the dementia care unit, and also a themed lounge / dining room with furniture and objects to promote reminiscence. People told us they could get and go to bed more or less when they wanted to, and could follow their preferred routines during the day. People were encouraged to bring in personal possessions. We observed that people in the dementia care unit could move around where they wanted to, (except into other peoples bedrooms). There were no visitors in the home during the inspection visit. (Visiting had been restricted due to an illness outbreak among people in the home and staff). Normally, people could have visitors at any reasonable time. Three relatives who returned our surveys said the home always helped the person to keep in touch with them, one said they sometimes did. Three relatives said they were always kept up to date with important issues affecting the person in the home, one said they sometimes were. The care records included details of people important to me so that staff were aware of the persons family and other people significant in their lives. There were records of contact with the persons family and friends. Two people who returned our surveys said they always liked the meals at the home. One person said, cannot fault the meals at all. One relative who returned our survey commented that there should be more on offer for those on liquid or soft diets. People we spoke with said they enjoyed the meals at the home and said they always had a choice. We observed lunchtime on the dementia care unit. Staff told us that the smaller lounge / dining room was not in use as the doors into it were too heavy for some people to manage and they were awaiting magnetic catches to hold the doors open. Consequently, all people in the dementia care unit used the main lounge / dining room and there were not enough places for everyone to eat at the tables. We observed that staff gave assistance as required in a sensitive way, ensuring dignity was maintained. For example, by providing protection for the persons clothes, and by sitting with people and giving help unobtrusively with eating and drinking. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There were satisfactory systems in place so that people were protected and effective action was taken to address their complaints. Evidence: Two people who returned our surveys said they knew how to make a complaint. One said they always knew who to talk to if they were unhappy about anything, one said they sometimes did. Two relatives who returned our surveys said they knew how to make a complaint, two said they did not know. Two relatives said the home had always responded appropriately to concerns raised, two said the home said usually had. One relative said that some concerns raised had been dealt with promptly, but other matters had still not been addressed. The complaints procedure was displayed in the main entrance area and was also included in the homes Statement of Purpose and Service User Guide. According to the AQAA, the complaints policy had not been reviewed since November 2006. We looked at records of complaints and these showed that complaints were dealt with promptly. The records showed the outcome of the complaint and any action taken. No complaints had been made directly to CSCI about the home since the last inspection. Care Homes for Older People Page 18 of 30 Evidence: There were satisfactory policies and procedures in place about safeguarding vulnerable adults, including a whistleblowing policy to protect staff. According to the AQAA, the safeguarding vulnerable adults policy had not been reviewed since October 2006 and the whistleblowing policy was last reviewed in April 2007. Staff training records showed that all staff had received training about safeguarding vulnerable adults, mostly in 2008. Staff spoken with confirmed that they had received training and were aware of the correct procedures to follow if abuse was suspected. The home had followed the correct procedures for two safeguarding incidents in 2008. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean, suitably equipped and comfortably furnished so that people lived in a pleasant environment that generally met their needs and expectations. Although there was satisfactory day to day maintenance of the home, there were some specific areas that required work to ensure a safe and suitable environment for people in the home. Evidence: One person who returned our survey said the home was always fresh and clean, one person said it usually was. Two relatives commented the home was always clean. People we spoke with said the home was usually clean. We observed that the home was clean and free from offensive odours on the day of the inspection visit. The lounge areas were bright, spacious, comfortably furnished and had Christmas trees and decorations. The manager said the ground floor dining room was awaiting refurbishment, including new flooring, curtains and furniture. We received comments that this room could be cold, particularly on winter afternoons. As noted earlier in this report, the smaller lounge / dining room in the dementia care unit was not being used as the doors were too heavy for some people to push open. The manager said that magnetic catches were to be fitted to hold the doors open. Care Homes for Older People Page 20 of 30 Evidence: We observed that the television in the main lounge of the dementia care unit was not secure and could easily be moved by people. We observed one person attempting to move the television on two occasions until distracted by staff. Staff told us this person had attempted to move the television before. The manager said that it was planned to provide a television secured to the wall in this lounge area. There was no kitchen area in the first floor dementia care unit so staff had to go to the ground floor kitchen for all drinks - including water - snacks and meals. The bedrooms we looked at were bright and clean with peoples own possessions to personalise the room. Suitable equipment was provided, such as hoists for manual handling, grab rails, and adjustable height beds. In five of the homes bathrooms, the bath seats had been taken out of use in November 2008. Staff were able to use a mobile hoist to lift people in and out of the bath in four of these bathrooms. The manager said the bath seats were taken out of use because of a health and safety issue. She did not know when the seats were to be replaced. In two of the bathrooms, the bath panels were cracked and broken. In another bathroom the end bath panel had come off completely. In a ground floor bathroom there were tiles coming off the wall. In a first floor bathroom there was a gap in the floor covering around the toilet. There was a shower cubicle in a first floor bathroom that was not in use as the shower had been removed and the cubicle was not suitable for use by people with mobility problems. The laundry and sluice areas were suitably equipped. All of the care staff, and most of the other staff in the home had received training about the control of infection. Staff spoken with confirmed they had received this training. We observed staff using disposable gloves and aprons appropriately and staff told us these were always available. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a satisfactory recruitment system and good staff training so that people were protected and were supported by competent staff. Staffing levels were not consistent to ensure that peoples needs were fully met. Evidence: One person who returned our survey said there were usually staff available when needed, one said there sometimes were. Both people said staff listened to them and acted on what they said. Relatives commented about the staff: There is not always enough staff on to give the time my Mum needs to feed, staff are very professional and caring, care staff always polite and caring, put more staff on, I find the staff approachable and I can ask them things and question things, get on very well with the staff, and, very polite to visitors. People we spoke with said there were usually enough staff available to meet their needs. They said staff were very good, and all very nice. One of the staff who returned our surveys said there were usually enough staff to Care Homes for Older People Page 22 of 30 Evidence: meet peoples needs, two said there sometimes were, and three said there never were. Staff told us there were usually sufficient staff in the mornings, but not in the afternoons when there was one less care assistant on duty. The staff rotas showed that the usual staffing was a qualified nurse on each shift with a total of six care assistants in the morning and a total of five care assistants in the afternoon. Staff told us that this meant that there were two staff each on the ground and first floor and one staff floating between the two. This caused friction between staff on the two floors as inevitably the floating staff could not provide sufficient cover for both floors. The acting manager was aware of staff concerns and said the providers hoped to improve staffing levels soon. Six staff who returned our surveys and staff we spoke with said the required checks and references had been carried out by their employer before they started work. We looked at the records for three members of staff and found that they had all the required documents and information, such as a Criminal Records Bureau (CRB) disclosure and two written references. Five staff who returned our surveys and those we spoke with said their induction covered everything they needed to know very well, one said it partly did. Six staff who returned our surveys and those we spoke with said they had training to help them understand and meet peoples individual needs. We looked at staff training records and found that staff had completed an induction that met Skills For Care standards. Staff had received training as required, such as manual handling, food hygiene, fire safety, and safeguarding vulnerable adults. In addition, staff had received training about equality and diversity, caring for people with dementia, and managing aggressive behaviour. The AQAA said that 50 of care staff had achieved a relevant National Vocational Qualification (NVQ) Level 2 or above. 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 was well managed, and there were good systems in place to ensure peoples health, safety and welfare were promoted and the home was run in their best interests. Evidence: The acting manager was suitably qualified and experienced to run the home. She had been in post since September 2008, though had previously been acting manager at the home in 2007. The acting manager said she had started the application process to register with CSCI. Staff and relatives who returned our surveys, and staff we spoke with were pleased the acting manager had returned to the home. Staff told us they were confident the acting manager would take appropriate action to address any concerns raised. The AQAA had been completed by the acting manager. The AQAA contained clear, Care Homes for Older People Page 24 of 30 Evidence: relevant information supported by a range of evidence. The AQAA showed where the home had made changes and where they still need to make improvements. The data section of the AQAA was fully completed. The quality assurance system at the home included internal audits to ensure compliance with regulations and standards, annual satisfaction surveys of people living in the home and their relatives, and monthly meetings for people living in the home. Relatives were also offered a regular meeting, but these were often not attended by any relatives. The results of the annual satisfaction surveys were analysed and a report produced with details of what action was to be taken to address any issues raised. The AQAA showed that all checks of equipment and systems in the home had been carried out up to date. All relevant policies were in place, though none had been reviewed in the last twelve months - some had not been reviewed for more than two years. There were satisfactory accident records. The home had sent notifications to CSCI of various events as required under regulation 37. Care Homes for Older People Page 25 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 26 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 19 13 Action must be taken to ensure the television in the main first floor lounge cannot be moved by people living in the home. This will reduce the risks to the health and safety of people in the home. 31/01/2009 2 19 23 In the bathrooms: - the cracked and broken bath panels must be repaired or replaced - the tiles coming off the wall must be repaired - the flooring around the first floor toilet must be repaired or replaced This will reduce the risks to the health and safety of people in the home and provide a safer and more pleasant environment. 28/02/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards Care Homes for Older People Page 27 of 30 and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 7 There should be a consistent approach to the review of care plans and assessments. Care plans should be reviewed at least every month to ensure that peoples changing needs are monitored and appropriate care provided. People in the home, or their representatives should sign the care plans to indicate their involvement and agreement. Records of the disposal of medication should be signed by two members of staff. This will help to ensure a more robust system that protects people in the home. Where medication is prescribed as required, there should be details in the persons care plan of when the medication should be given and of any alternative action to try first. This will help to protect people and ensure medication is given as prescribed. Handwritten instructions on medication administration records should be signed by the person who has written them and countersigned by another person who has checked the instructions are correct. This will ensure a more robust system that protects people in the home. The smaller lounge / dining room on the dementia care unit should be put back into use as soon as possible to ensure people have sufficient space to enjoy meals, and to give a choice of communal space available to them. There should be consultation with people in the home and / or their representatives to improve the menu for people who need liquidised or soft diets. The home should ensure that all relatives and visitors are aware of the complaints procedure. This will help to protect people in the home and ensure that any concerns are properly reported. All policies and procedures should be reviewed at least annually to ensure they are relevant and include the most up to date information. This will help to protect people living in the home. A shower should be provided that is accessible to people with mobility problems. This would improve the choice of bathing facilities for people in the home. Action should be taken as soon as possible to ensure the bath seats are put back into use. This will ensure that people can be assisted to bathe safely and easily. There should be a kitchen area on the first floor so that people, or staff assisting them, have easy access to Page 28 of 30 2 3 7 9 4 9 5 9 6 15 7 15 8 16 9 18 10 19 11 19 12 19 Care Homes for Older People drinking water, other drinks and snacks. 13 19 The temperature of the ground floor dining room should be monitored and any necessary action taken to ensure the temperature meets the relevant environmental health and safety requirements and the needs of people in the home. There should be a total of six care assistants on the morning and afternoon shifts to allow consistent cover for both floors of the home. This will help to ensure that peoples needs are fully met. 14 27 Care Homes for Older People Page 29 of 30 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!