Inspection on 10/06/09 for Vicarage Court Nursing Home

This inspection was carried out on 10th June 2009.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Vicarage Court Nursing Home 05/06/08

Vicarage Court Nursing Home 01/06/07

Vicarage Court Nursing Home 15/09/06

Vicarage Court Nursing Home 30/11/05

Vicarage Court Nursing Home 27/07/05

Vicarage Court Nursing Home 12/01/05

Vicarage Court Nursing Home 07/07/04

Vicarage Court Nursing Home 16/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report Care homes for older people Name: Address: Vicarage Court Nursing Home 160 High Street Chasetown Staffordshire WS7 8XG     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Pam Grace     Date: 1 0 0 6 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 28 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Vicarage Court Nursing Home 160 High Street Chasetown Staffordshire WS7 8XG 01543685588 01543677034 morecare@tiscali.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Morecare Limited care home 39 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 39 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 (OP) 39 Physical Disability (PD) 39 Date of last inspection Brief description of the care home Vicarage Court is a 39 bedded care home with nursing, situated in Chasetown. It comprises of a purpose built building set in a town location, and close to a local shopping centre, and is also on a bus route. The proprietors Morecare Ltd., have run the home since it was first registered in 1995. The home is currently registered to admit 39 older people over the age of 60yrs, and comprises of single and double bedrooms, some of which have en-suite facilities. There are two lounge and dining rooms; other facilities include a hairdressing salon and conservatory. All areas of the home have access to a passenger lift. There are car - parking facilities. Care Homes for Older People Page 4 of 28 0 39 Over 65 39 0 Brief description of the care home Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate 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 overall quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key unannounced inspection was carried out over one day, by one inspector. The inspection had been planned using information gathered from the Care Quality Commission (CQC) database, the Annual Quality Assurance Assessment (AQAA) document that had been completed by the acting care manager and operations manager, comments received from people who use the service and their relatives. The key National Minimum Standards for Older People were identified for this inspection and the methods in which the information was gained for this report included case tracking, general observations, document reading, speaking with staff, people who use the service and their visiting relatives. A tour of the environment was also undertaken. Care Homes for Older People Page 6 of 28 The Statement of Purpose and Service User Guide were available for us to view. These had been reviewed and a new information pack was in the process of being assembled. The previous inspection report is available to read in the main entrance hallway of the home. At the end of our inspection, feedback was given to the acting care manager and the operations manager, outlining the overall findings of the inspection, and giving information about the recommendations that we would make. People spoken with were very positive about the care they were receiving. Comments have been included in this report. We observed people who were unable to communicate. Our observations showed that these people were well cared for, and were happy in their surroundings. There had been 3 complaints made to the home, since the previous inspection, these were not upheld, and had been dealt with in a timely way under the homes complaints procedure. There were no requirements, and 7 recommendations made as a result of this unannounced inspection. The current fees for this service range from £375.00 to £625.00 per week. The reader may wish to obtain more up to date information from the service. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? The Annual Quality Assurance Assessment completed by the acting care manager told us about the following improvements New care plans have been implemented and have received positive feedback from nursing staff and all other outside professionals. Care Plans are set up to meet all twelve daily living needs. A full fire evacuation had been put into place with all service users abilities documented staff have been trained and aware of the procedure if need to be implemented New equipment have been purchased for the comfort of our service users new fully profiling beds are being put into place. New Menus, better documentation of activities in care plans. Staff attending training. The home has made a step to encourage outside activity by encouraging the residents to go outside and look after the plants they have grown. Have purchased some new Patio Furniture to encourage relatives to sit outside when visiting the home. Staff attending training sessions. Staff meetings. Rooms regularly refurbished communal rooms redecorated with new furnishings. External furniture purchased for outdoor use. Some bedrooms have had carpet replaced by non-slip vinyl flooring to reduce staining and odour. Link nurses identified to reduce infection control and promote continence. All care staff and hospitality staff have either achieved or are working towards NVQ level2. Staff attended 1st Aid Training and Dementia Awareness. Training arranged for awareness sessions with external agencies such as continence and Palliative Care specialists. Care plans are under constant review and good practise are shared by both homes. Care Homes for Older People Page 8 of 28 Residents continue to have freedom of choice in all the daily living requirements. New handover system in place Fire evacuation process and matrix. 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 on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 28 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. Evidence: The Annual Quality Assurance Assessment document AQAA, which was completed by the acting care manager, told us: Relatives are encouraged to visit the home prior admission to discuss any concerns or worries. Every Service User has a pre assessment prior to admission this process is always carried out by the Care Manager and in some cases with both Care Manager and Operations Manager when a resident needs are continuing care funding, this enables a quick decision and all equipment is authorised as soon as required. Encouragement is given to service users family to bring into the home with them personal belongings such as photos etc to help the settling in process. Service Users families have always commented on the dedication of the staff and that the staff have Care Homes for Older People Page 11 of 28 Evidence: mostly been long serving with the company. Families are involved through every process of the initial care plan and are invited to review care plans at regular intervals. We were told that the Statement of Purpose and Service User Guide are in the process of being reviewed and we were shown the documents under review, these will be included in the homes new information pack, which will be given to all prospective people wishing to use the service and or their representatives. People spoken with confirmed that they had received appropriate information prior to admission, which had included the Statement of Purpose. That they had been able to visit the home, and spend time talking with people who use the service to help them decide if the service would be suitable for them. Comments included, we were made very welcome, and we were able to have a good look around with a member of staff. People also confirmed that they had been provided with a contract and or terms and conditions of service. Contracts were also in the process of being reviewed. We looked at three care plans. These showed that a full assessment of needs had been undertaken for those individuals on admission. The assessments gave good information about the persons needs across all activities of daily living examples being cognitive awareness, confusion, risk assessment including falls, bathing, moving and handling and fire safety. Intermediate care is not provided in this home. Care Homes for Older People Page 12 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. Evidence: The Annual Quality Assurance Assessment document AQAA, which was completed by the acting care manager, told us: Care Planning with a named Nurse and Key Worker system implemented and working well Regular meetings with outside agencies and residents families enabling Service Users to make their own choices and decisions whenever they are able to. Advanced directives are discussed and implemented with support from the McMillan Nurse if required. Personal care records are monitored by the Acting Care Manager and the key workers are also encouraged to be involved with documentation in the new care plans. Hairdressers, GPs, Chiropodists, Optician and Dental services visit the home on a regular basis. Staff attend regular in house or outside training sessions. We examined three care plans. All care plan documentation had been reviewed and Care Homes for Older People Page 13 of 28 Evidence: renewed since the precious inspection. We spoke with staff, people who use the service, and their visiting relatives. Staff spoken with could tell us exactly how each of these people were to be cared for, what these staff told us reflected what was written in individuals care plans. People we spoke to told us they had been involved in their care planning processes and their review. All three care plans contained evidence of a pre admission assessment, which had informed the care plan. There was also evidence of health professionals involvement, for example tissue viability nurse, physiotherapy, stroke nurse and dietician. There was also evidence that some details were recorded in the event of terminal illness, however not all care plans contained this information. Some assessment pro formas were undated, so it was not clear when they were reviewed. This was highlighted and discussed at the time with the acting care manager. Daily records seen evidenced that bathing had been undertaken dependent upon individual wishes and preferences. We monitored this because it had been raised as a concern during our previous inspection visit. Staff were observed interacting with relatives and people using the service. People and relatives spoken with during our visit said that they were very satisfied with the care that they and or their relative receive. One person said the staff were hardworking, kind and considerate. She said she was happy with her room, and said she knew it wasnt home, but she was comfortable. A spot check of medication administration procedures showed no anomalies, this included controlled medication. Eye drops were appropriately stored and dated. Oxygen cylinders were appropriately stored. There was an auditable trail for returned medication, and records were signed for by two people. Medication Administration Records were signed appropriately. We were told that Boots pharmacy were due to visit the home the next day to audit medication. Care Homes for Older People Page 14 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use services are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities are almost meeting individuals expectations. Evidence: The Annual Quality Assurance Assessment AQAA document, which was completed by the acting care manager told us: Activities planned around residents choices. Gardening club set up and running residents have grown their own vegetables and there is an ongoing competition on the tallest grown sunflower. Local newspaper has got involved with the pancake activities and photos with a small write up in the local weekly newspaper. New Care Plans have helped to incorporate all the Service Users daily and social needs together with the Map of Life. Service Users maintain contact with friends and relatives, social events encouraged. Activities are carried out from Monday to Friday and documented in the care plans. New Menus in place, Head cook spoke to each resident and devised a menu to cater for Service Users requests there is a wide choice of food, with a choice of cooked breakfast. Food likes and dislikes are documented in care plans Activities are also arranged through external services such as exercise to music. Members of Care Homes for Older People Page 15 of 28 Evidence: staff have attended Dementia Awareness Course to help identify appropriate activities for people with dementia. Service Users have TVs and radios in their rooms and can choose to spend quiet time in their own rooms if they wish. People spoken with told us we do a bit of gardening now, that keeps us busy, we had a lovely fete, and sold some of our potted plants there, we do a few more activities now, and its better than it was. We spoke with a staff member who had some responsibilities in regard to organising activities. she confirmed that people are asked what they would like to do, and that this is done by staff on a 1 to 1 basis. She said the following activities were on offer, 1 to 1 talking to people, reading to people, reminiscence groups, bingo, aromatherapy, manicures and pedicures, the new gardening club where people can set seeds, plant up pots, watering, growing tomatoes, sunflowers etc. The provider has bought two gazebos for people to use whilst in the garden. The group have plans to grow potatoes and runner beans. Pot plants were recently sold at the summer fete to raise money for outings. Visitors are able to see people in private if they so wish, there are no restrictions placed upon visitors unless asked to do so by the person using the service. Meals were eaten in comfortable and bright surroundings. There is a three weekly rotational menu which has been improved since the previous inspection, to include more choices of hot or cold meals as well as better choices for afternoon tea. There is also a cooked breakfast option twice weekly for people who want that option. These were introduced following discussion with people using the service. We sampled the main meal of the day, which was lamb cobbler, served with vegetables and potatoes. This was nutritious, tasty and wholesome, and people told us that they had really enjoyed their lunch. Staff told us that because staffing levels had improved, the level of activities had also improved. We looked at the kitchen, which was very clean and tidy. The cook, and records seen confirmed that all hot food temperatures are taken daily and recorded, this is as well as fridge and freezer temperatures. Care Homes for Older People Page 16 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to express their concerns and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. Evidence: The Annual Quality Assurance Assessment AQAA completed by the acting care manager told us: Good communication with service users families and staff. Open door policy for everyone including management and directors. All complaints are dealt with promptly and are documented as per company complaints procedure. Staff regularly have training to deal with any challenging issues and aware fully aware of the Whistle Blowing Policy. The AQAA told us that there had been three complaints received by the service since the previous inspection. These had all been amicably resolved, and none of those complaints had been upheld. Records were available for us to view. We saw that the complaints procedure was clearly displayed in the main entrance to the home. The operations manager confirmed that people who use the service and or their Care Homes for Older People Page 17 of 28 Evidence: representatives are provided with a copy of the homes complaints procedure during the admission process. The new information pack which will be available shortly, will also include the complaints procedure. People spoken with during the inspection visit confirmed that they had been given a copy of the complaints procedure, and knew who to complain to. They said that their grumbles are listened to and acted upon by staff. A grumbles book had been introduced. One relative spoken with said, the home has a lovely atmosphere, and staff always let me know if theres any problems, they keep in touch. Another person said, Im more than pleased with the service we receive here. The operations manager confirmed that the home has an open door policy in regard to complaints. There had been no Protection of Vulnerable Adults POVA Safeguarding referrals made to Social Services since the previous inspection. We spoke with staff, they were unable to remember or confirm whether they had received update or refresher training with regard to issues of abuse, its identification and types of exploitation. It is a recommendation of this report that safeguarding abuse training is undertaken by care staff. Staff recruitment records evidenced that appropriate Police checks had been undertaken prior to employment. Care Homes for Older People Page 18 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well maintained and comfortable environment, which encourages independence. Evidence: The Annual Quality Assurance Assessment AQAA completed by the care manager told us: The environment is safe well maintained and is exceptionally clean. The home has been fully recarpeted in all communal areas and may bedrooms have had the carpets replaced with non slip vinyl. Bedrooms are bright and homely and are always re decorated prior to a new service user being admitted. The home is always odour free and comments are always passed on the cleanliness of the home by external visitors and families. Continence promotion is high on our agenda as this helps with the cleanliness of the home The handy man regularly attends the home and follows the refurbishment program in discussion with the Care Manager. New curtains are now in place to give a warm and inviting feeling to the communal areas Outdoor communal areas are also well kept and are regularly maintained by external companies. Linen regularly replaced for a warm homely feeling for the service users. Towel and soap dispensers have been replaced in all communal areas. Care Homes for Older People Page 19 of 28 Evidence: People spoken with during the inspection visit expressed their satisfaction with the general environment, their bedroom, and the equipment provided within the home. People spoken with said, its kept clean by the staff, and they work hard to keep things nice for us. We observed that the home provides a clean, well maintained environment throughout. The programme of carpet replacement, and refurbishment continues. Carpets upstairs had been replaced on the corridor, and in the lounge diner area, this was the same as downstairs, which had been replaced last year. New non slip flooring had also been fitted to the dining area. We were informed that new wheelchairs were on order. Accommodation is personalised to suit individuals. Communal areas are comfortable and homely. Bathrooms and toilets are conveniently sited around the home. We noted that equipment and adaptations were provided as necessary to maximise independence. For example, wheelchairs, raised toilet seat, bed rails, pressure mattress, handrails, and assisted baths. Bed rail bumpers were in place where needed, to promote the comfort and security of the people using the service. Care plans showed that risk assessments were in place and up to date for those in use. Kitchen and laundry areas were clean and tidy, with appropriate measures in place to prevent cross infection. Care Homes for Older People Page 20 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home should be trained, skilled and in sufficient numbers to support the people who use the service. Evidence: The Annual Quality Assurance Assessment AQAA document, completed by the acting care manager told us: Good skill mix of staff on each shift Good staff induction and training of current staff. Employment checks prior to commencement of work always take place Staff fully informed of all service users needs, and are involved with documentation in care plans. Regular Staff meeting held for all staff Regular comments on staff from families and visitors staff are always welcoming and well informed Regular training sessions for all staff All staff including non care staff are enrolled for an NVQ qualification when they have completed they induction and probation period Agency staff only used in an emergency. Staff supervision now take place. At the previous inspection there had been some concerns noted in regard to the staffing levels at the home. The staff rota for June showed that there needs to be an additional qualified member of staff on the late duty and the overnight duty, and also showed that there needs to be one carer less on the late duty and the overnight duty. This was highlighted and discussed with the operations manager. We were also told Care Homes for Older People Page 21 of 28 Evidence: that there is a shortfall of staffing at the moment, and that active recruitment is taking place. The staff rota for June and July 2009 confirmed that staffing levels are being maintained with agency cover as required. Staff spoken with confirmed that staff supervision was not consistent, and that staff meetings had only recently been resurrected. They confirmed that they had received appropriate induction into their role and responsibilities, however, there was no evidence to support that this was the case. Updates are needed in regard to mandatory training, including moving and handling, health and safety, and first aid, and staff could not recall when they had last undergone training in relation to abuse and safeguarding of vulnerable adults. We requested a copy of the homes staff training matrix. Three staff recruitment files were examined. One person was awaiting a security check, and was supervised on each shift. The other two contained appropriate security and police checks, and evidenced a good standard of procedures from an administrative point of view. The new acting care manager has only been in post for the past two months. She is aware of the need to become registered. The home still needs a permanent registered care manager, this has yet to be achieved, and does affect the overall quality rating for the home. Care Homes for Older People Page 22 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Short term arrangements and management input by the operations manager is effective. The home should further develop its quality assurance system to make sure that services are provided in the best interests of those who use them. Staff should be trained and competent to do their jobs. Evidence: The Annual Quality Assurance Assessment AQAA completed by the care manager told us: Good systems in place to monitor service users and staff Good Care Plans with positive feed back from other professionals Good networking between Sister home Part time Trainer employed to support Managers with in house training. Open door policy with senior management Care managers have required administration days to manager the home Thorough risk assessments in place Care Manager has the support of Operations Manager on a daily basis. Care Manager is committed and positive and Care Homes for Older People Page 23 of 28 Evidence: always strives to make improvements in the home. Residents finances are regularly audited and checked by the manager. Equipment is regularly serviced and checked to ensure all health and safety is adhered. There had historically been no registered manager in post for the past year, with the operations manager acting up in that role. The new acting care manager knows the home well, and has been in her present post for the past two months, having previously worked for the servicce. She is also very aware of the need to be registered with the Care Quality Commission (CQC). Because this is yet to be achieved, it does affect the overall quality rating for the home. The Annual Quality Assurance Assessment (AQAA) document, which was completed by the acting care manager, was returned to the Care Quality Commission on time, and was completed to an adequate standard. The statement of purpose and service user guide, in line with Schedule 1 of the National Minimum Standards has been reviewed, and a new information pack is in the process of being put together. This will ensure that prospective people wishing to use the service receive appropriate information. The operations manager has improved the care planning process used by the service, and new care plans were clear, and contained comprehensive information about the person using the service. However, work still needs to be done in relation to staffing levels, staff supervision, training, induction, and the full implementation of the Quality Assurance system. There had been three complaints made to the home since the previous inspection. These had not been upheld. During observation of the environment there were no health and safety issues identified. This was because of continuous vigilance and monitoring by management and the staff team, ensuring the safety of people who use the service. Care Homes for Older People Page 24 of 28 Are there any outstanding requirements from the last inspection? Yes R No £ 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 1 38 13(4) The registered person shall 05/06/2008 ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated Key U/I undertaken by Pam Grace on 10/06/09. Observation of the environment showed no anomalies. Confirmed with the acting care manager and operations manager that the monitoring of health and safety within the home is undertaken by the management on a daily basis. Management said that they are now much more vigilant in regard to this. Visit by HSE on 23/09/08 made recommendations which have also since been met. Care Homes for Older People Page 25 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 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 14 Consideration should be given to formalising meetings for people using the service, to evidence that these are taking place. Staffing levels should be reviewed in line with recommendations made by the Department of Health. Staff should receive a formal and recognised induction, which is in line with Skills for Care. Staff should receive training according to their role and responsibilities. This should include regular update and refresher training in regard to Safeguarding and Abuse of Vulnerable Adults. To comply with legislation a registered care manager should be appointed. A more comprehensive quality assurance system needs to be implemented which encourages and seeks feedback from people who use the service, their relatives and or representatives, and other visitors to the service. This information should be acted upon and outcomes feedback through staff and meetings for people using the service. 2 3 4 27 30 30 5 6 31 33 Care Homes for Older People Page 26 of 28 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 7 36 Staff should receive formal supervision at least 6 times per year, in line with the National Minimum Standard. Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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