Inspection on 27/02/09 for Westhorpe Hall Residential Home

This inspection was carried out on 27th February 2009.

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

Westhorpe Hall Residential Home 10/07/07

Westhorpe Hall Residential Home 18/07/06

Westhorpe Hall Residential Home 01/02/06

Westhorpe Hall Residential Home 20/06/05

Westhorpe Hall Residential Home 18/01/05

Westhorpe Hall Residential Home 20/09/04

Westhorpe Hall Residential Home 10/03/04

Westhorpe Hall Residential Home 21/11/03

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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 19/06/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Westhorpe Hall Residential Home Westhorpe Hall Residential Home Westhorpe Stowmarket Suffolk IP14 4SS     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: Jan Sheppard     Date: 2 7 0 2 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 26 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Westhorpe Hall Residential Home Westhorpe Hall Residential Home Westhorpe Stowmarket Suffolk IP14 4SS 01449781691 F/P01449781691 melonieml0@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr K Hunt care home 21 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Westhorpe Hall is a listed country manor house set in its own grounds and in the village of Westhorpe. It has much character, and has been converted to provide longterm residential care for up to 21 older people. The house is approached by a private drive that crosses an ancient moat. There is car parking and gardens that are accessible to the residents. The main house offers accommodation on ground and first floor, with a modern single storey extension to one side. The ground floor comprises two sitting rooms, dining room, kitchen, office, bathroom, WC?s, and several bedrooms in the newer wing. Six of these are set aside for residents with dementia. A wood-burning stove had recently Care Homes for Older People Page 4 of 26 Over 65 6 21 0 0 Brief description of the care home been installed in the main lounge, replacing the open fire. The first floor is served by two staircases, both fitted with stair lifts, to two separate wings. The remaining bedrooms, two bathrooms and WC are on this level. In total there are 15 single bedrooms and 3 doubles; one of the doubles is being used as a single room. Four of the single rooms are less than ten square metres in size, and one of the double rooms is just under sixteen square metres. The latest revisions to care standards make these rooms sizes acceptable, on the basis that these facilities were registered before the NCSC came into being. On the first floor of the home, there are several changes of floor level, which have to be negotiated, and a number of doorways have raised lips. This poses some limitations on the needs they can meet in terms of residents mobility. Fees for the home are between 355 pounds and 550 pounds per week Care Homes for Older People Page 5 of 26 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 inspection was unannounced and took place over seven hours on a weekday. This was a key inspection that focused on the key standards of the Care Standards Act 2000 relating to older people. The report was written using accumulated evidence gathered prior to the inspection, including information contained in the AQAA, ( Annual Quality Assurance Assessment) completed by the Manager, information given in the pre inspection questionnaires completed by residents, staff,relatives health professionals;and also takes account of statutory notifications sent periodically to the CSCI by the home. During this inspection the inspector made a tour of the building, had in depth discussions with the homes manager and deputy manager met and spoke with a number of the residents and spoke with staff and visitors.Spot checks were made on a number of the homes records. Care Homes for Older People Page 6 of 26 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.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 7 of 26 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 8 of 26 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 use this service can expect to receive an assessment of their care needs prior to their admission to the home. Evidence: The files of a number of newly admitted residents were seen and each one contained a pre-admission assessment. The Manager or deputy manager visits each new applicant to the home visiting them either in their own homes or in hospital and where appropriate also talking with their relatives and friends. Since the last inspection improvements have been made to the scope of this initial assessment so as to include all aspects of the applicants current care needs including personal hygiene, mobility, diet, continence , cognition, past medical history and current medication needs. A life history record is also compiled this having been found to be information particularly needed for new residents suffering with dementia to ensure that their care needs can be fully understood and met from the outset of their admission to the home. Care Homes for Older People Page 9 of 26 Evidence: People who had recently moved into the home spoke positively about their experience. They felt that they had received a warm welcome. One said the staff were very kind and helpful when I first arrived. Another recently admitted resident who had moved at her request from another home spoke very positively about this admission experience It was so much better planned than for the previous home she said, the staff went out of their way to thoroughly understand my care needs and how I like to have things done and this really helped me to settle in quickly. The home has a detailed statement of purpose and service users guide and brochure which gives clear information setting out the aims and objectives of the home and the services provided.All prospective residents are given an opportunity to visit the home prior to admission and to speak with and share a meal with the existing residents. Care Homes for Older People Page 10 of 26 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. People who use this service can expect to have a person centred care plan and to have their health and social care needs met in a respectful and dignified manner. The homes medication practises offer protection to the service users. Evidence: Since the last inspection the residents care plans have all been reviewed and additional details as to how care is to be delivered to meet all their assessed needs more fully recorded. Four care plan records were examined. These were all found to be fully up to date and to have good detail of the assessed care needs,good detail of the service users preferences and clear risk assessments.The care plans for the service users with dementia all contained a record of their life history and the manager said that she now intends that every resident will have their life history recorded in this way as knowledge of this enables better person centred care to be given and for the residents with dementia enables staff to acknowledge and respond to them as the person that they were. The care plans were seen to be subject to a Care Homes for Older People Page 11 of 26 Evidence: regular review and evidence of service user involvement with this review could be seen.The plans were seen to contain records of the residents weight and the monitoring of their nutritional needs. Where required pressure area care was recorded this to compliment the assistance given with this aspect by the visiting district nurses. The home has good links with local GPs and pharmacists. One local G P with a special interest in the care of the elderly holds a weekly surgery in the home and residents consulted all said that any request that they make to see a doctor is always promptly met. All new residents are registered with the Continence service a visiting Chiropodist and Optician and where needed with the CPN mental health service. The AQAA stated that all residents are assessed for their ability to self medicate prior to admission.The home uses a MDS monitored dosage system of medication storage and administration which is provided from a local pharmacy.The manager said that the pharmacist gives prompt service with good support and some training. Records evidenced that all staff who administer medication have been trained to do so and a list of their signatures is kept.Medication reviews are undertaken by the visiting GP on an annual basis. Medication is stored in a locked cabinet in the dining room. Part of a medication administration round was observed during this inspection and staff were heard to be explaining appropriately to the recipient resident and to be administering and recording the medication in a safe manner.The MAR ( medication administration record) sheets were found to be accurately maintained with no gaps in recording and good notes of any irregularities kept on the reverse of the sheet.The manager makes regular checks of the accuracy of these MAR sheets. A check was made of the Controlled drugs ;these were found to be correctly stored and the administration records tallied with the controlled medication held. Over the warmer summer months the manager will be monitoring the temperatures reached in the medication storage cupboard. Residents spoken with all said that they received very good care and that they were always treated with great respect and dignity.Staff were seen to be relating to the residents in a warm and caring manner. They were observed to be knocking on residents room doors before entering and residents who are able are offered a key to their room.One resident said there is such a lovely homely feeling in this home and the carers are always patient and kind and the food is fantastic!. Care Homes for Older People Page 12 of 26 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 this service can expect to be encouraged to maintain contact with family and friends, to be offered a range of activities and to have a well balanced diet. Evidence: Feedback from residents and relatives confirmed that the standard and variety of the food continues to be very good.The manager explained that since the last inspection and following consultation with the residents the menus have been revised to include new dishes requested by individuals. One resident who prefers to spend much of her time in her room said the cook visits me every day to ask what I would like and will often provide an individual alternative. The serving of the lunchtime meal was observed. The meal smelt extremely good and residents confirmed that it was hot and appetising. A daily menu stating also numerous alternatives is displayed in the dining room in large letters on a blackboard and a visual menu is also maintained.Staff who were serving the meal clearly had good knowledge of individuals likes and dislikes and were heard to be asking residents about portion sizes. Where staff assistance with the eating of the meal was required this was seen to be done in a calm appropriate manner giving just the level of support needed whilst still encouraging the resident to do as much for themselves as they could manage. The meal period was quite protracted thereby accommodating the slower eaters and enabling a relaxed Care Homes for Older People Page 13 of 26 Evidence: atmosphere between staff and residents with much conversation between them to develop. The kitchen was visited and found to be well appointed, clean and tidy. Temperatures of refrigerators and freezers are recorded daily and showed that they were functioning within safe limits. The kitchen had been subject to an inspection from the local environmental health department on the 23rd October 2008 from which there were no outstanding requirements. A wide range of dry ingredients and fresh fruit and vegetables were seen to be appropriately stored.Risk assessments for all residents regarding accessing the kitchen have been added to each service users care plan since the last inspection.One service user who visited the kitchen to speak with the cook was seen to knock on the door and then it was noted that the cook spoke with her at length about how a favourite dish of hers should be prepared. The cook said that she had good training opportunities and that the kitchen followed the procedures set out in the Safer Food Better Business guidelines. She confirmed that the ingredients she requests are always provided promptly and that advice from a Dietitian is promptly sought for example where there is a risk of malnutrition of swallowing difficulties. Staff had a good awareness of the need for good hydration especially in hot weather and residents who want can have supplies of fresh fruit and water in their rooms. The home provides a very wide range of daily activities for the residents who wish to participate and a weekly plan was seen to be displayed. Since the last inspection the home has employed a dedicated activities co-ordinator and she has made individual assessments of the activity needs/wishes of all the residents written records of which could be seen in the care plans.Various members of staff also lead activities and were seen to be doing so with individuals and small groups during the afternoon of this inspection visit.All of the residents consulted said that they had plenty of activities and several mentioned the beautiful gardens and the new garden log cabin which they were looking forward to being able to use in the warmer weather.The list of activities offered included flower arranging,cake making, painting, bingo, chair exercises, craft classes preparing items of the summer and Xmas Fairs using the mobile library going for walks in the grounds, quizzes,reminiscence groups and bird watching. One resident has chosen to help prepare vegetables and several residents were seen to be being assisted by staff to complete the daily newspaper crossword.Activities are offered both individually and to small groups. A range of outings into the near locality are planned for the warmer summer months and a number of individual entertainers visit the home especially around the Xmas period.Residents mentioned their enjoyment of the singing of the choir from a local school and the visits from a Pat Dog.Residents are assisted to follow any religious observance and various of the local churches make regular visits to the home. Residents are enabled to make and receive phone calls in private at any time.Relatives told the inspector that the home makes every effort to ensure that all residents have sufficient activities to meet their needs and interests in Care Homes for Older People Page 14 of 26 Evidence: an individual way. Care Homes for Older People Page 15 of 26 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. Practises in this home ensure that people who use the service can be confident that the policies and procedures in place will ensure that they are listened to and are protected from abuse. Evidence: The homes Statement of Purpose and Service Users Guide clearly explains the complaints procedure. All the residents spoken with knew who to talk to if they were not happy and wanted to complain.Several told the inspector that whilst they would register a formal complaint if needed they would first mention any problems to the Manager who they felt confident would sort things out promptly. She is always very approachable and organises changes quickly,one said.Another resident said that I cant think of anything that I would not be happy about I am very well cared for here and can talk freely to staff and managers when ever I want. Since the last inspection the home has received one complaint which was not upheld.The complaint did not relate to the care of any resident. The homes records evidenced that this matter was dealt with professionally and promptly. The whistle blowing policy is displayed in the home. Staff spoken with had a good understanding of this and one mentioned that the new manager had recently gone through this with them reminding them of their obligations. Staff spoken with also demonstrated a sound understanding of the homes policies and procedures concerning Adult Protection and their understanding of the correct referral Care Homes for Older People Page 16 of 26 Evidence: routes for any suspected abuse.The training records evidenced that this training for all staff was up to date . The home has never had a POVA incident and following discussion the Manager and deputy Manager agreed that they would undertake further training on this subject so as to keep fully up to date with all aspects of this. The manager had attended Mental Capacity Act and deprivation of liberty training since the last inspection.Other senior staff are to attend this training shortly. The home has proper procedures in place to deal with behaviours that may challenge the service and any incidents are recorded in care plans and a risk assessment carried out to give full protection for the service user. Care Homes for Older People Page 17 of 26 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. Westhorpe Hall provides a spacious comfortable environment which has a homely atmosphere. Residents benefit from a home which is well maintained comfortable clean and hygienic and is well appointed with all the appropriate facilities to meet their needs. Evidence: A tour of the building identified it as a spacious well appointed home that is also well maintained.The home which is a heavily beamed and moated small manor house is set in beautiful and well maintained grounds on the edge of a small village. Every effort has been made to adapt and appoint this beautiful old house so that it safely meets the needs of its residents.Every resident spoken with and visiting relatives also mentioned their appreciation of the homely atmosphere of the building and the beauty of the grounds with its wildlife and flowers. Since the last inspection works to strengthen the fencing around the moat and to add more alarms to the external doors of the home have been undertaken.The homes records evidenced that the handy man makes regular checks of the security of the fencing around the moat.The homes garden space has been suitably adapted with patios for sheltered sitting and the completion since the last inspection of a wooden garden cabin in which it is planned that a range of activities can take place during the summer months.The residents many of whom came from the surrounding rural areas spoke enthusiastically about these outdoor facilities and of the opportunities they have Care Homes for Older People Page 18 of 26 Evidence: to undertake minor gardening works.Also since the last inspection various works of redecoration and re carpeting have been carried out. The manager said that new residents are given a choice of colours if their room is to be redecorated and each bedroom seen was very well personalised with small items of furniture, pictures, ornaments and photographs.All the residents spoken with confirmed that they were very happy with their rooms and one spoke positively about the prompt assistance given to her when she first moved in by the homes maintenance person in assembling her room just as she wanted it it did help so much with enabling me to quickly feel at home she said.Bedrooms for double occupation were seen to have the appropriate screening and the manager commented that many such rooms were now occupied singly. Overall the home was found to be very clean and had no malodours. One bedroom carpet with some staining required to be cleaned or replaced. The home has two lounges and a separate spacious dining room. All of these rooms give easy access to the gardens and were found to be comfortably furnished. The large lounge has a wood burning stove in an inglenook ( the stove is safely protected) and this was seen to provide a focus to the room on the day of this inspection. One resident said it is so lovely to sit by a real fire just like I did in my childhood. The laundry area was visited this has direct access to the garden and was found to be well appointed with good attention being given to infection control measures gloves aprons being readily available. The use of red bags for soiled linen would further improve these measures. Residents were all very complimentary about the standard of their linen and the speed at which freshly laundered items were returned to them.The manager said that when occasionally things do go wrong and items are damaged a reimbursement is always made. On the day of this inspection residents were seen to be well dressed with properly ironed clothing of their choice. Staff were seen to be assisting residents using the stair chair lifts and into the assisted bathrooms. Residents confirmed that they can choose how often and when to have a bath. Care Homes for Older People Page 19 of 26 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. People who use this service can be confident that they will be supported by appropriate numbers of skilled and trained staff who have been robustly recruited to protect them and to ensure the smooth running of the service. Evidence: During this unannounced inspection it was seen that there were sufficient staff on duty to meet the residents needs in an individual manner.Staff and visitors spoken with during this inspection said that staff were always available to meet their needs quickly and during the day of this inspection a number of staff were observed to be giving residents individual one to one attention . One resident said staff are always available to help us and nothing is ever too much trouble for them. The appointment files of three staff whose recruitment is currently in process were examined and it was found that all the required checks had been made or were in process.The manager said that new staff do not commence duties until CRB or POVA first checks have been completed and then they work under supervision until an induction training has been completed.The home is fortunate in being able to retain a very stable group of long standing staff many of whom have worked at the home for many years and who live in the locality and therefore know many of the residents who have also lived in the locality well. The manager explained that the current vacancies had arisen because of maternity leave and because the work visas of two staff expired Care Homes for Older People Page 20 of 26 Evidence: and they had to return to their home country. All the staff spoken with during this inspection confirmed that they were well managed and supported by the homes manager and by the new deputy manager. They said that they have good training opportunities both with external training and training that is arranged internally. Since the last inspection there has been an increase of staff holding NVQ qualifications and four staff are currently studying for this at either levels 2 or 3.Staff spoken with had a positive attitude to wards training and two said that they were keen to progress onto level3. The homes training records evidenced that during the past year a number of training courses had been attended including manual handling November 08, safe food handling and POVA training in September 08, Infection control August 08,Stoma care and waterloo and musk assessment and medication training, Fire Awareness in December 08 and all staff have now attended Yesterday Today and Tomorrow training in Dementia care.Mental Capacity Act training is being undertaken by the managers and senior staff at the end of February. The homes records evidenced that regular staff meetings are held and that these occasions are also used for training purposes. Minutes are kept and these showed good participation by the various groups of staff who are also encouraged to raise their own items for the agenda. Care Homes for Older People Page 21 of 26 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. Residents benefit from the sound management of the home and the homes person centred ethos ensures that it is run in their best interests. Administration practises in the home protect residents and promote a safe environment. Evidence: The home benefits from having a management team who are well qualified and experienced and whose shared ethos is very clearly to put the needs of the residents first. Their confident and calm approach to their work positively influences the homely and relaxed atmosphere in the home. Since the last inspection a new deputy manager has been appointed and it was explained that it is intended that she takes over the managers role later in the year.She holds NVQ qualifications at level 3 and is currently studying for Level 4 of the registered managers award. She has had many years experience working in the field of elderly care at both carer and management levels.She explained that the senior Care Homes for Older People Page 22 of 26 Evidence: carers now all hold professional qualifications so that this means that at all times the person in charge of the home is appropriately qualified.All the management team continue to undertake regular training to update their knowledge and to keep abreast of new developments.Relatives interviewed at this inspection confirmed that the manager and her team are always very approachable and make every effort to sort out any problems quickly.Relatives and other visitors said that they were always made to feel very welcome. The new deputy manager discussed with the inspector the review of how the home was operating that she had been undertaking since her appointment and she mentioned several areas where she would want to make further quality improvements. The home has a quality assurance system in place and evidence from recently completed surveys is being used to inform this improvement review.Quality surveys are regularly sent to relatives and other professionals and the results of these are regularly fed back to the staff as part of their ongoing learning process to continually improve the service they offer.The management is committed to promoting equality and diversity in the service and in meeting the individual needs of the residents. The records evidenced that an annual supervision plan is in place in the home to ensure that all staff receive formal supervision at least six times a year.Annual appraisals are also completed although these were one month behind their planned dates at the time of this inspection. The records relating to fire testing, the monitoring of water temperatures,legionella testing, risk assessments for the environment and safety checks for the homes equipment were all seen to be well maintained this ensuring the safety of the residents at all times. The home has a policy and procedures for the protection of residents monies held by the home and records of these that were checked were all found to tally. The required records( receipts) relating to expenditure and other records of transactions were also seen to be properly maintained. Staff questioned had a good awareness of the homes policy concerning the acceptance of gifts. Care Homes for Older People Page 23 of 26 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 24 of 26 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 18 It is recommended that the manager and deputy manager attend refresher training on Adult Safeguarding. Care Homes for Older People Page 25 of 26 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). 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