Inspection on 02/10/08 for Valentine Lodge

This inspection was carried out on 2nd October 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

Valentine Lodge 08/10/07

Valentine Lodge 14/05/07

Valentine Lodge 29/01/07

Valentine Lodge 14/06/06

Valentine Lodge 01/02/06

Valentine Lodge 26/04/05

Valentine Lodge 22/11/04

Valentine Lodge 29/06/04

Valentine Lodge 18/02/04

Valentine Lodge 15/10/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Valentine Lodge 28 Edith Road Canvey Island Essex SS8 0LP     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: Diane Roberts     Date: 0 2 1 0 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: Valentine Lodge 28 Edith Road Canvey Island Essex SS8 0LP 01268696955 01268696955 valentinelodge@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Valentine Lodge Limited Type of registration: Number of places registered: care home 20 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: 20 The registered person may provide the following category of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Valentine Lodge is registered to offer accommodation with nursing care for twenty older people. The home is situated near to local amenities and transport on Canvey Island. There are shared bedrooms on the ground floor, all with a toilet, wash basin and shower, and five single bedrooms on the first floor with hand washing facilities. There are two lounges and a dining room downstairs and there is a passenger lift. There is limited parking to the front and side of the home and an enclosed garden area to the rear. The weekly fee range is #457 to #525 per week. Additional charges/costs Care Homes for Older People Page 4 of 30 Over 65 20 0 Brief description of the care home are incurred by residents relating to chiropody, purchase of some personal toiletries and hairdressing. 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: We visited the home for a whole day and met with the manager and her team. Prior to this we reviewed all the information that we already had on the home and this included the managers Annual Quality Assurance Assessment. The manager was asked to complete this and this tells us how well they think are doing, what they do well and what they would like to improve upon. We refer to this throughout the report as the AQAA. The manager was given some guidance on completion of this document for future reference as some of her evidence was limited. On the day of the inspection we spoke to residents, relatives and staff at the home and prior to that we sent out surveys to all these parties, asking for feedback on the home. The response was quite good and these comments are referred to in the report. Whilst at the home we also reviewed records and undertook a tour of the home. Care Homes for Older People Page 6 of 30 Care Homes for Older People Page 7 of 30 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 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 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. Residents thinking of moving to the home can be assured that they will have enough information about the home on which to base a decision and that they will be fully assessed to ensure that the home can meet their needs. Evidence: The manager has both a statement of purpose and service users guide in place. These were reviewed. The service users guide requires review in relation to the format, so that it is suitable for the resident group and more user friendly. The content of the guide also requires some review to ensure it covers the required areas, as outlined in Standard 1 of the National Minimum Standards and the complaints procedure is not in full, for example, the address of the Commission is not included. The statement of purpose was complete and up to date. The manager has a system in place for the assessment of prospective residents to the home and she tends to undertake all of the assessments required. Completed Care Homes for Older People Page 11 of 30 Evidence: assessments were reviewed and found to contain a good level of information and also gave an outcomes section, which confirmed the assessors judgment as to whether the home could meet that persons current care needs or not. The assessments contained some social and family information, but overall were very needs/nursing led. Discussion was held with the manager about bringing a more person centered approach into assessment that will then lead into the care planning. In addition to the completed assessment there was also appropriate information from the referring authority. Relatives and residents spoken to and who commented, said that we were told we could visit the home at any time suitable to us, no need to make an appointment - the manager said find us as we are, when we visited, we toured the home, had a long chat with the manager, met staff and took a brochure. I have settled in well to the home, it took a while but its fine now and the staff at Valentine, made my relative feel so welcomed, we are very pleased. On the surveys residents all commented that they had contracts in place and that they all had enough information when deciding on the home. This was also confirmed by relatives who commented. Brochures, the statement of purpose, service users guide and last inspection report are all available in the main hallway. 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. Residents can be assured that they will have a detailed plan of care to help ensure that staff know how to meet their needs. Evidence: The manager has a care planning system in place and care plans were reviewed in detail. Overall care planning in the home is good and continues to improve. Residents care needs are identified and planned for in such detail that staff who did not know a resident well should be able to care for them with confidence. The manager has developed a person centered approach to much of the care planning with good preferences and choices shown, but this could be developed further. There is good evidence of reviews and all the care plans seen were up to date. Reviews could be enhanced by developing a more person centered, as well as needs led approach to this aspect of the plan. Care plans were seen to promote residents independence and maintenance of skills. Care plans in relation to general wellbeing/mental health and social care require further development and this was discussed with the manager. Discussion with staff regarding the residents care plans tracked showed that they knew Care Homes for Older People Page 13 of 30 Evidence: the residents well and the content of the care plan. The care plans contained a range of risk assessments for individual residents. These were seen to be up to date and contained sufficient detail on the risk and the management. Consideration should be given to developing a nutritional risk assessment to identify residents at risk or steady deterioration. It is evident from records and discussion with staff that there is a very proactive approach to residents health care needs. Staff are prompt in taking action when they note a cause for concern and refer appropriately. Records show that residents have good access to their GP, opticians, chiropodists, physiotherapists and specialist nurses. Records show that residents are regularly weighed and any concerns or needs are identified in the care plan. It was noted that residents who were admitted with weight loss have steadily put on weight and their health has improved. At the current time there are no residents in the home who have pressure sores and the there was observed to be a good supply of pressure relieving equipment. There are also no residents in the home who require any ongoing wound management. Residents and relatives comments on the standards of care provided in the home include they look after my relative very well, the staff look after my relative as if they were their own, my relative loves it here, the staff contact you if anything is wrong, nothing is too much trouble for the staff, they explain everything, my relative always looks well and cared for, I feel safe and looked after here, if you ring the buzzer staff come quickly and if they are delayed they come and explain why and the staff always make sure that you are alright and dont leave you until they are sure. Residents who commented in the surveys returned, primarily stated that their care needs were usually met. It may be of value to review care plans with the residents to ensure that they agree, where possible, as the care plans did not always show evidence of resident involvement. Medication administration practices were reviewed and have improved since our last visit to the home. Administration sheets were clear and neat and medications had been checked in and accounted for. Odd signing omissions were noted. Liquid medications were seen to be dated for auditing and expiry purposes, residents as and when medication had individual guidance for staff on administration and residents photos were in place. Controlled medications were checked and found to be in good order with appropriate records. Since the last inspection the manager has worked on the timing of the medication rounds to ensure medications are not given at inappropriate times and this was seen to have improved. The manager had on file Royal Pharmaceutical Society advice from 2003. More up to date information needs to be issued/available to staff. Care Homes for Older People Page 14 of 30 Evidence: Interaction between the staff and the residents was seen and heard to be friendly, caring and appropriate. Residents spoken to said that staff respect their dignity and their privacy when providing personal care and in general. 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. Residents living at the home are given opportunities to take part in social activities but planning in a more person centered way would help to ensure their needs are met in full, as far as possible. Evidence: From discussion with the residents and staff and review of the care plans, the routines of the day are resident led as far as possible. Staff demonstrated an understanding and appreciation of residents rights and choices, they also were well aware of individual preferences and these were also reflected in the persons care plan. It was noted that staff did not always know a residents social history and this should be developed. Comments from residents include I went to another home but did not like it, here they get me up when I want to get up and we do the activities if we want to and if we dont then we dont and I like to spend time in my room, you can spend time where you wish. All the residents who commented in the surveys said that the staff always listened and acted upon what they said. The manager in her AQAA says we give residents the right of choice in all areas of care and this is identified in their individual plan. Care Homes for Older People Page 16 of 30 Evidence: The home benefits from having an activities officers that works part time. The officer said that she chats to the residents and asks them what they would like to do. A programme was displayed up on the wall in the hallway, but this is not always followed if residents choose to do something different. The activities programme could be made more available to all residents. The manager in her AQAA said we could improve by making sure that residents know the choices available to them. Activities include, watching films, target games with bean bags, competitions, sing songs, music, crafts, quizzes etc. The activities officer has also organised more events this year, such as barbecue and fêtes, which are well attended by family and friends and help to raise money for more activities. The officer sometimes takes residents out to the shops and in the summer the garden is available to them. Some residents have one to one time and this consists of chatting and passing the time. Activities records show what residents will do and how well they participate etc. Activities in the home could be developed further. Fuller social histories and assessment of social needs and wellbeing would help this, along with a more targeted, person centered approach. One to one sessions do need to be more focused in order to stimulate residents and the promotion of independence, self worth and daily living skills needs to be brought into the social care plan. This was discussed with the manager and the activities officer. Residents spoken to and who commented said that I Like to read books, I dont want to play games or anything and I enjoy the activities, especially ball exercises. Residents who commented in surveys said that, on the whole, activities were always available to them. Residents confirmed that their families and friends were made to feel very welcome when they visited and relatives spoken to confirmed this. Relatives also commented positively regarding the social events at the home. Information on advocacy services was seen to be available in the home. Mealtime was observed throughout the home. The meal provided looked appetising, with fresh vegetables and residents and staff sat and ate together. Residents were noted to be helped appropriately and sensitively. The tables are nicely laid and residents have access to condiments. There are no specialist diets provided at the current time apart from soft diets and where needed, staff were seen to be using prescribed thickening agents. The menu was displayed and residents spoken to knew what was for dinner. Residents were seen to have access to drink during the day, as well as at mealtimes. Residents spoken to and who commented said that the food is good, steak and kidney pudding today -very nice, you can have what you want for breakfast - they will just do it for you, including anything cooked, its very good and sometimes there is a choice with the main meal sometimes not but if you dont like it they will make you something else. Care Homes for Older People Page 17 of 30 Evidence: A nutritional record is completed which evidences residents choices and records how much they have eaten. The manager and the cook have a file of residents food preferences and how they like their meals, size etc. Care Homes for Older People Page 18 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. Residents and relatives can feel confident to raise concerns at the home and know that they would be dealt with properly. Evidence: The complaints procedure is displayed in the main hallway and can be found in the service users guide as well. Since the last inspection the manager has not received any complaints but does have a logging system in place should one occur. Residents surveyed all knew how to make a complaint and who to raise it with. Residents spoken to said I would feel comfortable to raise any concern, the manager comes to see me most days and she asks if I am happy and if everything is fine and I see the manager quite a bit and would raise any concerns with her. Relatives said that I am perfectly happy and if not I would discuss anything with the manager and I have nothing bad to say about the home. The manager in her AQAA states that staff and visitors know how to make a complaint and whom to approach. The evidence would concur with this. The home was seen to have compliments from relatives that included we appreciate how you looked after our relative. It was a short time but the care was excellent and thank you for the kindness shown to my relative I know they were happy with you. Since the last inspection the manager has referred one safeguarding issue to social Care Homes for Older People Page 19 of 30 Evidence: services and this was seen to be dealt with appropriately and records maintained. The manager needs to obtain the most up to date local authority procedures to ensure the correct ones are followed in the future. Staff spoken to demonstrated an understanding of adult safeguarding matters and procedures for reporting. Staff spoken to confirmed that they had attended training and the staff training matrix showed that whilst there were some gaps in staff training on this subject, the manager confirmed that these were to be booked. The manager is keeping up to date with training on this subject and has also recently attended training on the deprivation of liberties which will affect homes in the near future. Care Homes for Older People Page 20 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. Residents live in a home that meets their needs and continues to improve, making it a more pleasant place to live. Evidence: Since the last inspection the proprietor has continued with the redecoration/refurbishment of the home. A tour of the home was undertaken with the manager and it was evident that a lot of decoration work had been undertaken. All of the bedrooms have been repainted and approximately 50 of them have new sets of bedroom furniture and some have new curtains. The home has eight single and 6 double bedrooms. The bedrooms are of a good size and those residents spoken to who shared rooms were happy with the arrangement. Residents bedrooms were seen to be personalised. The bathrooms have yet to be refurbished and they do require some work to bring them up to date, however they remain fit for purpose. Some residents have had the showers replaced in their en suite facilities although there remains some ongoing issues with the hot water supply in the home. The manager evidence that they have been getting these matters addressed, by plumbers as they are noticed. The management of the home are hoping to improve the bathrooms with a local authority grant and replace some more carpets in the home. Lighting has been improved in the Care Homes for Older People Page 21 of 30 Evidence: corridors and the corridors are being painted and new pictures will be put up. The manager in her AQAA states that we continue to update furniture and decor to provide a comfortable environment for all our residents to live in. The home benefits from having two lounges, one to the front and one to the rear of the home. The front lounge is pleasant, well decorated and homely. The rear lounge has been painted but as yet, has not been dressed and is therefore not a very stimulating place to spend time. The manager acknowledges this and confirmed that this will be attended to. Since the last inspection the garden and outside seating area for residents has been improved and made a more pleasant place to spend time, with planted flowerbeds and pots. The home was seen to be very clean and no odours were noted. The home has a maintenance man who attends on an as required basis. Records are maintained of water temperature checks but these were not as consistent as they could be. Fire safety arrangements in the home were reviewed. The manager has a fire safety risk assessment in place along with other associated risk assessments. It is recommended that these are streamlined and kept together to give an overall picture. The risk assessments were up to date along with testing of the fire alarms etc. The last fore drill was noted to be March 2008. It is recommend that these take place more often. Residents and relatives who commented on the home said that I am happy with my room, its always clean, when we chose the home the decor was an issue but the staff were so good we overlooked that and we are happy with my relatives room, everything is kept tidy. Relatives who commented in surveys on how the home could improve, highlighted the decor as being the main area for improvement and staff surveys also concurred with this. Residents commented in surveys that the home was always fresh and clean. Care Homes for Older People Page 22 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. Residents are cared for by a competent and generally well trained team who continue to develop to ensure that residents needs can be met in full. Evidence: Staff turnover at the home is relatively low and at the current time, no agency staff are used. This provides residents with consistency of care. The manager has on duty in the morning 1 RGN and 3/4 care staff. The manager is supernumerary but is also a very hands on member of staff as the team work closely together. In the afternoon there is 1 RGN and three care staff and at night 1 RGN and 1 carer. Random samples of the rota concur with this and the rota shows that the home is adequately supported by an ancillary team. The manager states that she uses feedback from the care team and relatives and residents to help her decide on the staffing levels and also does provide escorts to hospital appointments where necessary. In addition to qualified nursing staff, the manager employs ten care staff of whom 4 have achieved NVQ level 2. Records submitted by the manager confirm that there are six staff currently undertaking this qualification, which will take the home over the 50 recommended level in the future. Staff files were checked to assess the recruitment procedures at the home. These were Care Homes for Older People Page 23 of 30 Evidence: found to be very good and contained all the required checks and documentation, including references and criminal bureau record checks. Staff surveyed confirmed a robust recruitment procedure. It was disappointing to note that there were gaps in the staff induction system. The manager has introduced Skills for Care into the home but there was an inconsistent approach, despite the manager allotting staff time for this. It is acknowledged that the induction is supplemented with in house training sections but the shortfalls need to be addressed. The training matrix showed that staff are generally up to date with manual handling, infection control, fire safety and food hygiene. Gaps in training generally relate to new staff and the manager can evidence booking of sessions planned. Staff have also completed training in health and safety and first aid. Additional training has been provided to staff diabetes management, tissue viability and sensory deprivation. It is positive to see that two of the nursing staff have attended course in palliative/end of life care and liaise closely with external agencies on this matter. Consideration should be given to updating nursing staff in clinical skills such as wound management. Staff spoken to and surveyed confirm that training at the home is good and equips them to do their job effectively Care Homes for Older People Page 24 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 manager strives to run the home is the best interests of the residents and staff which helps to ensure good outcomes. Evidence: The manager has worked at the home for 17 years, more recently as the manager. She is currently undertaking the registered managers award and records show that she keeps up to date with training and attends appropriate local events. Staff spoken to found the manager approachable should they wish to raise any matters. The manager combines staff and residents/relatives meetings together, the last meeting was in July 2008 and the next is booked for October 2008. The meetings are very inclusive and feedback is given on the running of the home and consultation is offered on matters that affect residents. Staff commented that they work at the home as its a friendly place, good atmosphere everyone gets on and I like the residents, the home is known for its friendliness, we Care Homes for Older People Page 25 of 30 Evidence: try to make it homely not institutional, my manager supports me in all the tasks I have to do and families are welcomed and they become friends and often visit years after their families have left us. The manager has a quality assurance system that she has developed and the questionnaire are due to be sent out to residents and relatives. From the analysed results the manager plans to develop an action plan and let people know the results. In addition to this the manager carried out internal audits on the medication. It is recommended that she extends this to other areas such as training, staff supervising and induction, to ensure that standards are maintained and improved upon. The manager confirmed that the home still does not hold any personal monies on behalf of reside ts living in the home. No health and safety issues were noted on touring the home. A random sample of safety and maintenance certificates were reviewed and found to be up to date and in order. Accident record were reviewed and found to be appropriately completed and followed up where required. 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 1 18 18 All staff working in the home 31/12/2008 should have training in adult safeguarding matters To ensure, as far as possible that residents are safe from abuse 2 19 23 Those parts of the home still 31/01/2009 requiring redecoration and refurbishment need to be addressed. To ensure that residents have a pleasant and comfortable home to live in 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 A review of the service users guide should be undertaken, ideally with residents input, to ensure it is user friendly and contains all the information they would require. Work should be carried out to involve residents in the care planning process as far as possible Care plans should continue to be developed in a person centeed way consideration should always be given to a persons wellbeing and social care. Page 28 of 30 2 3 7 7 Care Homes for Older People 4 5 9 12 Up to date pharmaceutical advice should be available for staff. Following consultation with residents, continue to develop the social side of care in the home in a person centered way so that all residents needs are met as far as possible. This should include social histories and assessments of need. Up to date policies and procedures should be available for staff on adult safeguarding. Whilst the management are addressing issues with the hot water system in the short term, consideration should be given to putting a long term plan in place to address this issue overall Continue to encourage staff with NVQ qualifications. Improve upon the staff induction programme, giving a more consistent approach. Consideration should be given to developing internal audits of systems in the home, such as training. 6 7 18 19 8 9 10 28 29 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. 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). 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. 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