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Inspection on 11/12/08 for Thomas Colledge House Care Home

Also see our care home review for Thomas Colledge House Care Home for more information

This inspection was carried out on 11th 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 3 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

The environment is of a very high standard. Each bedroom is for single occupancy and has a toilet and shower. The home has three wings with a lounge come dining room on each wing. There are no steps anywhere within the home. The home is clean, well decorated with good quality furnishings. A relative spoken with said that, "it is like a hotel". There is suitable equipment available for people with mobility and sensory difficulties. The staff team are well-trained, experienced and knowledgeable. There is a low turnover of staff and many staff have worked at the home for a number of years. Health and safety is given a high priority, with training for staff and all records and checks in good order. People living at the home and staff are regularly asked their views about the service and are consulted about planned changes, or any ideas someone may have. Meals are of a very good standard with a choice provided. One person spoken with during the inspection visit said, " dinner was beautiful today, it always is". Staff were described by visitors as welcoming, pleasant and polite. Residents at the home spoke very highly of staff. Comments included, "I can`t fault anything, staff are always kind and helpful" and, "staff always find time for each one of us". Staff spoken with confirmed that they worked well as a team and they were aware of the importance of respecting people`s privacy and dignity. Residents and staff spoken with all said that all the management team were approachable and they felt able to go to them with any concerns.

What has improved since the last inspection?

Since the last inspection visit there has been an extension built onto the home, creating an additional eight places. The original residents were offered the opportunity to have one of the new bedrooms if they wished to do so. The extension has been built to the same good standard as the original home. The laundry and kitchen facilities have been improved, including new equipment. There is now a monthly trip for residents, using community transport as well as regular entertainers coming into the home. There has also been a new manager since the last inspection visit. Although the manager has not yet registered with CSCI which needs to be done as a matter of urgency, she has the required management qualifications and was spoken well of during the inspection visit. Although all staff are trained, several longer-term staff had not had the relevant refresher training, however these were all booked for early 2009. There is now a storage room for safe storage of medication, and a new hairdressing room. The registered provider has agreed to additional staffing. This includes hours to undertake laundry duties, clerical duties and additional care staff hours. These additional hours will be advertised in early 2009 and will further improve the service provided.

What the care home could do better:

Although there was a statement of purpose displayed in the reception area, this was out of date. The service user guide had been revised, however no one spoken with wasaware of this document. Some of activities were organised for people living at the home however staff were not following the activities programme on display. The recording book for activities had several days where there were no activities recorded. It was unclear whether this was due to lack of activities or poor recording. Several residents spoken with said that there were not a great deal of activities planned, but many people were happy to sit quietly, do crosswords, listen to music or read. There were some minor errors found within the medication system at the time of the inspection visit, and the manager had notified CSCI of discrepancies with controlled drugs recording. The manager confirmed that she was closely monitoring this to ensure improvements were made. Staff records were not available at the home to check that recruitment practices were safe.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Thomas Colledge House Care Home Oxcroft Lane Bolsover Chesterfield Derbyshire DE45 1TB     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: 1 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. 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 © (2008) 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: Thomas Colledge House Care Home Oxcroft Lane Bolsover Chesterfield Derbyshire DE45 1TB 01629537495 Telephone number: Fax number: Email address: Provider web address: thomascolledgehouse@derbyshire.gov.uk Name of registered provider(s): Name of registered manager (if applicable) Derbyshire County Council Type of registration: Number of places registered: care home 24 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 24. The registered provider may provide the following categories of service only - Care Home only - PC to service users of the following gender - either - whose primary care needs on admission to the home fall within the following categories: Old age - not falling within any other category - OP. Date of last inspection Brief description of the care home Thomas Colledge House care home is a purpose-built residential home providing personal care for service users over 65 years. The home offers a good standard of accommodation. The care home is situated near to the town centre of Bolsover. There are three wings to the care home. There are no stairs, making the building fully accessible. All bedrooms are equipped with en-suite facilities, including showers. The 24 single rooms all have patio doors opening onto the attractive garden areas. Three of Care Homes for Older People Page 4 of 30 Over 65 16 0 Brief description of the care home the rooms are used for respite care. There are three lounge/dining room areas, and bathrooms with assisted bathing facilities. Fees are £392.18 per week for permanent service users, but a range of prices for short term care service users. Extra charges are made for hairdressing, chiropody, magazines and newspapers. 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 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 23 people living or staying at the home on the day of the inspection. 8 residents, 4 staff, 2 visitors, the deputy and manager were spoken with during the visit. We also looked at all the information that we have received, or asked for, since the last key inspection on the 2nd January 2007. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. Care Homes for Older People Page 6 of 30 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: Although there was a statement of purpose displayed in the reception area, this was out of date. The service user guide had been revised, however no one spoken with was Care Homes for Older People Page 8 of 30 aware of this document. Some of activities were organised for people living at the home however staff were not following the activities programme on display. The recording book for activities had several days where there were no activities recorded. It was unclear whether this was due to lack of activities or poor recording. Several residents spoken with said that there were not a great deal of activities planned, but many people were happy to sit quietly, do crosswords, listen to music or read. There were some minor errors found within the medication system at the time of the inspection visit, and the manager had notified CSCI of discrepancies with controlled drugs recording. The manager confirmed that she was closely monitoring this to ensure improvements were made. Staff records were not available at the home to check that recruitment practices were safe. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience 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 people have a comprehensive assessment of their needs completed by the care manager from Social Services and an initial care plan. A letter is issued which confirms the arrangements for care. There was a statement of purpose displayed in the reception area. However this was dated 2002 and had not been revised to include the new manager, and information concerning the extension to the building. Although there was a service user guide available, residents spoken with were not aware of this document. The manager explained that this document should have been given to people on their days Care Homes for Older People Page 11 of 30 Evidence: assessment. There was no record being kept of this document being given. The manager explained that everyone came for a day assessment prior to being admitted unless they were admitted in an emergency. People living at the home confirmed this, although most people had stayed for respite care before deciding to live at the home. One person said, I came quite a few times for one week at a time, then decided it was the right place for me to live. Another person said, when I first came staff helped me to settle in and showed me where things were. 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. Peoples health and personal care needs are met and the principles of respect, dignity and privacy are put into practice. Evidence: The information in the annual quality assurance assessment completed by the manager said that residents are viewed as individuals and receive person centred care. They are encouraged at all times to maintain their independence. Dignity, choice and privacy are given high priority. There is good access to local health care, including residents retaining their own GP. Medication training is provided and positive feedback given by the training assessors. During the inspection visit three residents files were seen. Two of the files were in good order with an assessment and care plan completed by the care manager from Social Services, as well as a personal service plan completed by staff at the home. There were relevant risk assessments in place including a nutritional assessment, prevention of falls, self administration of medication and a moving and handling plan. Care Homes for Older People Page 13 of 30 Evidence: Weight was recorded monthly and the key worker completed monthly written reviews. The third persons file that was seen was an emergency admission three weeks previously. There was very little documentation in the file other than a days assessment partially completed and daily logs. The manager explained that there was a care plan very recently completed by the care manager on the computer system that had not been printed off and therefore was not available for care staff. There was not an up to date assessment or personal service plan for this person. The person and their relative were spoken with during the inspection visit. They were very happy with the care provided and the persons needs were clearly being met. Although the annual quality assurance assessment completed by the manager said that residents are asked if they want a copy of their personal service plan, no one spoken with could remember this, and one person said that they would like to see their plan of care. There was evidence in files and people confirmed that staff would contact the GP or district nurse as soon as necessary and access to other health care services for example opticians and chiropody was available. One relative spoken with said, my mother had a chest infection and the doctor was called quickly. One person spoken with was at high risk of pressure sores and had the appropriate equipment necessary for the promotion of tissue viability and prevention of pressure sores. One of the managers was observed administering medication. This was done following good practice guidelines. The medication administration records generally showed good practice, however the codes to be used when a person does not take medication were not been used consistently. There was a new medication storage room which was a big improvement from the previous system. The home had recently changed pharmacists and reported improvements in the service. Medication administration records showed that one person had not had their medication for four days. It was explained by the manager that they were out of stock and a repeat prescription had not been requested in time. Eyedrops being administered to one person did not have the date of opening in place, making it difficult for staff to know when the 28 days for discarding was due. There was a system for returning medication. However the returns book was completed but did not have a signature of a witness. The manager had reported to CSCI several errors concerning controlled drugs within the past few months. As a result of this she was monitoring practice. At the time of the inspection visit controlled drugs and the register was in good order. However some care staff signing and witnessing administration of controlled drugs had not received training for this. Derbyshire County Councils medication policy clearly states that, the administration of a controlled drug must be witnessed by a second, suitably trained member of staff. Staff were observed treating people with respect, knocking before entering peoples Care Homes for Older People Page 14 of 30 Evidence: bedrooms, and residents spoken with confirmed that they felt their privacy and dignity were respected at all times. Individual records stated peoples request concerning their last wishes. The homes policy was to continue to care for residents if their needs can be met,with the support of the local health care team if they become terminally ill. 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. The range of activities was generally good, and the food provided was excellent which met the needs and wishes of people living at the home. Evidence: The annual quality assurance assessment completed by the manager said that residents could choose how they wished to spend their time including use of their rooms. Consultation takes place to ensure that residents are involved in the development of the programme of activities. The home has allocated hours for activities, supported by a member of the management team. Visitors and people from the local community are encouraged to visit the home. An independent advocacy service is available for residents. During the inspection visit staff and residents were spoken with about activities that were arranged. Several people said that they were happy to spend time in their bedroom watching TV. Other people enjoyed crosswords, word search and reading. Volunteers were at the home playing bingo with residents during the visit. This is a weekly event. Activity records showed that activities organised included dominoes, crafts, bingo, sing along, card games, beer, chips and skittles night and a video and Care Homes for Older People Page 16 of 30 Evidence: drinks trolley on Friday and Saturday night, which was free. There was a weekly activities plan displayed outside the managers office, however two staff spoken with said that they were not aware of this and it was evident that it was not always being followed. The activities record showed that there were several gaps where activities had either not taken place or had not been recorded. A staff member said that there was bingo on Thursday and Saturday, but not always time for other activities. The staff rotas showed that there were no additional staff hours for activities and care staff were expected to organise activities as part of their care duties. There was however a monthly outing organised using specialist transport. They had recently had lunch at a garden centre and were due to go out to a local hotel for Christmas dinner. Regular entertainers were brought into the home paid for from the amenities fund. Minutes from the residents meetings said that people enjoyed the last two entertainers. These minutes showed good consultation with people around activities and social events. People have said that they would like a newsletter and a pie and pea supper. At the last meeting, residents commented that the jigsaws being used were too small. The manager had agreed to look into specialist jigsaw for people with a sight impairment and large print crossword. Three visitors were spoken with and they all said that they felt very welcomed and could visit their relatives in private if they wished to do so. Residents spoken with confirmed that they had brought some personal possessions with them. One person said, I brought all my family photographs to put in my bedroom, it helped me feel at home. Everyone spoke highly of the food provided. One person said, the food is smashing and another person said, all the food is lovely, but you ought to taste the sponge cakes we have, they are out of this world. A worker was seen in the morning telling everyone the menu for lunch and tea time and asking them if they would like an alternative. However the menu displayed did not reflect the days menu. The cook was spoken with. She confirmed that there was always a cooked lunch and also a cooked tea two days per week. She has a list of likes and dislikes and caters for people that are diabetic. She described how she likes to try new ideas and had recently made sponge with fresh raspberries and cranberry mince pies. 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. People who use the service are able to express their concerns and are protected from abuse. Evidence: The annual quality assurance assessment completed by the manager said that the complaints procedure was available in alternative formats if required. All complaints would be investigated promptly. Written policies are available on whistleblowing to support staff to report poor care practices. Full records are maintained of financial transactions involving staff with residents personal money. The management of finances are now raised routinely on review. Residents are registered to vote and are supported with postal votes. During the inspection visit the manager explained that she had devised a new recording system for formal and informal complaints as well as compliments. There had however been none to record. The complaints procedure was displayed in the reception area. A group of residents were spoken with and they all said that they would feel happy to bring up a complaint if they had one and would go straight to the office. One person said, we cant complain about anything, it is home from home. Training records showed that staff had undertaken training in safeguarding adults. Staff spoken with were aware of the importance of reporting poor practice if they saw Care Homes for Older People Page 18 of 30 Evidence: this. One staff member said, the happiness and safety of all the residents is our top priority. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is of a very high standard, above the national minimum standards which means that people are very comfortable, safe and their independence is supported. Evidence: The annual quality assurance assessments completed by the manager said that, they provide high quality en suite accommodation including eight larger bedrooms equipped for use by wheelchair users. The bathrooms in these rooms include level access showers. Residents meetings and reviews are used to consult with residents about the home, its decor and facilities. The laundry facilities have been improved by a new laundry room with additional equipment. The kitchen has been extended and new fittings provided throughout. There is now a hairdressing facility which has been well received by the hairdresser and residents. A tour of the premises took place during the inspection visit. The service has recently been extended to include an additional eight places. The environment is of a very high standard with large bedrooms and en suite shower and toilet facilities. All bedrooms have a lockable external door, many of which give direct access to the garden or patio area. There are three wings, and each wing has a lounge and combined dining area. Communal areas were bright, clean, warm and airy. The furnishings are new and were Care Homes for Older People Page 20 of 30 Evidence: of a good quality. Resident spoken with said that they were very comfortable. Several people commented on the cleanliness of the home. A relatives spoken with said that, its just like a hotel. There were good facilities and equipment provided to assist people with mobility difficulties. The manager explained that there was a loop system in one of the lounge areas, but the present residents with hearing impairment did not wish to use this. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff training provided is of a very high standard to ensure that staff provide a good quality of care. Evidence: The annual quality assurance assessment completed by the manager said that they had a stable care team who know the residents and their needs well. Staff turnover is low and several staff have worked at the home for many years. The staffing levels provided meets the needs of the residents. Additional staffing is authorised if required. During the inspection visit the staff rotas were seen. They showed that there were always two care staff on duty at all times of the day and night. There was also a manager or deputy manager on duty on the morning and afternoon shift. This was a slight increase in care staff hours since the addition of the eight places, as previously there were times in the afternoon where there was only one care worker and a manager on duty, which is no longer the case. At the time of the inspection visit the majority of residents at the home had low level needs. The staffing levels met the needs of the present residents, however with additional duties including activities and laundry, they were very busy. The manager explained that there had been recent agreement from the registered provider that additional staffing would be provided. This included additional care hours, some laundry hours as well as administrative Care Homes for Older People Page 22 of 30 Evidence: support for managers. It had been agreed that they could advertise for these hours in January 2009. This was likely to improve the quality of the service provided and increase the amount of time that staff can spend directly with residents. Training records were seen during the visit. There was an excellent induction programme provided for new staff. New care assistants spoken with said that they were not allowed to start until they had completed their moving and handling training, then shadowed an experienced worker for two shifts before starting work. Soon after this they completed numerous other courses including an introduction to social care, work in safety, first aid, food safety and developing as a worker. All existing staff had either undertaken all mandatory training or were booked on refresher courses in the near future. 13 out of 15 care staff had completed NVQ 2 Care, and the two remaining were new staff. This is above the 50 minimum standard and should be commended. All staff were booked on dementia awareness training in the New Year. Two staff files were seen. These showed that the manager kept a copy of the application form and references, as well as an e-mail from human resources stating that the CRB check had been completed and was satisfactory. However one persons application form did not have a full employment history, and there was no interview records to check whether this was discussed at interview. There was a copy of only one reference in the file. The manager explains that only one reference was sent to them by human resources, although two would have been received. All residents spoke very highly of the staff. Comments included, staff are kind and helpful, they always find time for you, even when they are busy. Another person said, staff come as quickly as they can when I ring the buzzer, but sometimes we have to be patient. Another person said, staff are smashing. Relatives visiting the home on the day also spoke highly of the staff. One person said, people are ever so nice, what more could you ask for. Another person said, staff are welcoming, will offer me a drink, I have even been offered a glass of wine. One relative said, we are quite satisfied with the care, staff do their best and managers keep me up to date, the cleaning staff keep things lovely and clean . 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 effective quality assurance systems, ensuring that people are listened to and the home continues to develop and improve. Evidence: The annual quality assurance assessment completed by the manager said that the home seeks to run for the benefit of residents, and staff seek to implement all Derbyshire County Council policies and procedures. The manager has been in post for over a year, however she still has not registered with CSCI. During the inspection visit she explained that her application was initially sent and returned as incomplete. It was then sent a second time but not received. The manager is aware that this now needs urgent attention. The manager is experienced and qualified with the Registered Managers Award (RMA) and NVQ 4 Care. She is also an NVQ assessor. She has worked in other homes for a Care Homes for Older People Page 24 of 30 Evidence: number of years. The manager is supported by a service manager who visits on a regular basis. The service manager completes monthly reports. These reports show evidence of relevant checks on records, as well as talking to staff and residents. The service manager was present during the inspection visit and it was evident that they were knowledgeable about staff and residents. The manager was also supported by a team of deputy managers. There has been some sickness amongst deputy managers, as well as new managers taking up positions. The manager hopes that they will continue to develop as a management team. Since the manager has been in post she has introduced a number of improvements including regular trips for residents using community transport as well as encouraging students from Chesterfield College undertaking the Health and Social Care course. The students usually become involved in short-term projects or activities. One student has asked to remain as a volunteer at the home as a result of their placement. Staff and residents were spoken with about the management team. Everyone felt happy to go to them for any reason. A staff member said, you can have a chat with a manager and know that it is confidential. The manager works to the book, she is fair and will listen. Residents and staff meetings regularly took place. The manager held separate meetings for staff doing different roles for example Kitchen, care and domestic. This gave staff the opportunity to talk about their particular roles and discuss any issues or concerns. The minutes of residents meetings showed that people were happy to make suggestions and the action plan written after the meeting showed that the suggestions were acted upon if possible. There was also an annual quality assurance completed by an external quality assurance manager. The results of these were displayed in the reception area. However there were concerns that there was a delay of 9 months between residents and staff completing questionnaires to then receiving the outcomes. The outcomes displayed showed a very high level of satisfaction. The only area that was marked as fair by residents were activities. All other areas were marked as good or excellent. The previous recommendations made at the last inspection visit had all been met. The manager confirmed that there was a safe system for keeping and recording service users money that was regularly audited, however this was not checked during this inspection visit. Care Homes for Older People Page 25 of 30 Evidence: Record showed that staff supervision was regularly taking place. These records showed that guidance was given during supervision for example one record showed a discussion concerning equal opportunities. It also gave staff the opportunity to voice concerns, resolve potential conflicts and receive praise. All records required by regulation and for the effective and efficient running of the service were maintained and up-to-date. Records were secure, locked in the main office. Staff were kept fully up-to-date concerning safe working practices including moving and handling, fire safety, first aid and food hygiene. Hazardous substances were safely stored. Information from the manager was that regular servicing of all systems and equipment were taking place. A sample of these were seen. They were found to be in good order apart from the emergency lighting test certificate that was out of date by almost 3 months. The manager agreed to attend to this immediately. Accidents were recorded and reported if required. CSCI were notified of relevant incidents, although the manager was not aware of the need to report deaths of all residents, whatever the circumstances. Care Homes for Older People Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 14 There must be a completed needs assessment and personal service plan for anyone admitted as an emergency as soon as is reasonably practical after the admission. This is to ensure that the care home is suitable for the purpose of meeting the persons needs. 12/01/2009 2 9 13 There must be an effective system in place to ensure that no residents run out of their prescribed medication. This is to ensure the health of residents. 19/12/2008 3 31 8 The manager must register with CSCI. This is so that CSCI can assess that the manager is a fit person to manage the service. 12/02/2009 Care Homes for Older People Page 28 of 30 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 1 1 The statement of purpose should be revised to ensure that there is up-to-date information available for people. The service user guide should be made available to everyone at the home as well as prospective residents to ensure that people have full information about the service provided. Consideration should be given to providing people with a copy of their up to date personal service plan to give them the opportunity to read them and see if they are receiving the care that has been agreed to meet their needs. Medication that needs to be discarded within a specific time period should have the date of opening recorded to assist staff to follow the pharmacists guidelines and promote peoples health and welfare. Staff witnessing and signing for controlled drugs should receive appropriate training to ensure that they are fully aware of their responsibilities and for the promotion of residents health and well-being. The recording system for returning medication should include a person signing that they have witnessed the recording of the medication to ensure a safe medication system. Activities provided on a daily basis should be recorded in sufficient detail, including recording people being offered and refusing to take part in order to evidence that sufficient activities and stimulation is being provided to meet everyones needs. Consideration should be given to providing staff hours for dedicated activity time to ensure that activities still take place at busy times. Evidence of safe recruitment practices should be available during the inspection visit to ensure that all the required recruitment regulations are met. Notifications of all deaths, illness and other events as stated in Regulation 37 of the Care Home Regulations should be reported to CSCI to ensure that CSCI have upto-date accurate information about the service. The emergency lighting test should be up to date and a certificate available at the home to ensure that emergency lighting is in good working order. 3 7 4 9 5 9 6 9 7 12 8 12 9 29 10 37 11 38 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 © (2008) Commission for Social Care Inspection (CSCI). 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