Inspection on 16/02/09 for Woodlands Care Home

This inspection was carried out on 16th February 2009.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Woodlands Care Home 09/03/10

Woodlands Care Home 10/02/10

Woodlands Care Home 22/07/08

Woodlands Care Home 20/08/07

Woodlands Care Home 30/09/06

Woodlands Care Home 06/03/06

Woodlands Care Home 01/11/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings 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: Woodlands Care Home Fairfield Road Broadstairs Kent CT10 2JU     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: Penny McMullan     Date: 1 6 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 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 30 Information about the care home Name of care home: Address: Woodlands Care Home Fairfield Road Broadstairs Kent CT10 2JU 01843860998 01843862865 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Ashbourne (Eton) Limited care home 33 Number of places (if applicable): Under 65 Over 65 33 old age, not falling within any other category Additional conditions: 0 The maximum number of service users to be accommodated is 33. The registered person may provide the following category/ies of service only: Care home with nursing only - (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). Date of last inspection Brief description of the care home Woodlands Care Home is a purpose built two-storey building set in gardens next to Fairfield Manor Care Centre, both of which are owned by the same company. Ashbourne (Eton) Ltd is the registered company, which is a subsidiary of Southern Cross Healthcare. Accommodation comprises of thirty bedrooms that are all currently used as singles, but this number includes three larger rooms that can be used as doubles. All bedrooms have en-suite toilet facilities. There is a lift to the first floor and ample bathroom and toilet facilities. Communal areas consist of the main lounge, a very small lounge and dining room. There is a well-kept garden to the side and patio area at the front of the building for residents use. Shared parking facilities are available to the front and the home is located in a residential area on the outskirts of Care Homes for Older People Page 4 of 30 Brief description of the care home Broadstairs. The home offers personal and nursing care. There is always at least one registered nurse on duty, with a team of carers and ancillary staff that deal with cooking, cleaning, laundry, administration and maintenance. The fees for support from the home are set during the assessment period and are very specific to the needs of the individual, depending on the level of support required and the staffing numbers provided. At the time of this inspection the fees range from 396.54 to 850.00 pounds. 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: A random inspection was carried out on 15th September 2008 to check compliance with the Statutory Requirement Notice, dated 19 August 2008 and the requirements made at the last key unannounced inspection on 22nd and 23rd July 2008. At that time the organisation had taken steps to improve the staffing levels and it was decided that we would not proceed with further enforcement action. This key unannounced inspection will monitor compliance and assess the overall rating of the home. The new manager, who has been in post for three weeks, assisted throughout the visit and at times the Operations Manager was also in attendance. Surveys were sent to the home for the owners to distribute to people that use the Care Homes for Older People Page 6 of 30 service, staff and professionals who have contact with the service. All comments received from surveys, and discussions with the people who live in the home, their relatives and staff have been included throughout this report. The care of three people was tracked to help gain evidence as to what it is like to receive care in the home. Various records were viewed during the inspection. The home returned the Annual Quality Assurance Assessment (AQAA) within the required timescale. The current Manager was not in post when the AQAA was completed, so therefore did not complete the document. Information within the AQAA was satisfactory and in some areas indicated what the home has achieved or how they intend to improve their service. The AQAA did not show how the home had complied with the Statutory Requirement notice regarding staffing levels or mention how other requirements and recommendations have been complied with. The maintenance of equipment section in the AQAA was not completed. Improvements are therefore required when completing the next AQAA. What the care home does well: What has improved since the last inspection? What they could do better: To ensure the care plans provide staff with clear moving and handling guidelines. The daily records are legible and reflect the care given at that time. Care plans to clarify when a review has taken place and detail how to achieve individual outcomes. To provide all staff with safeguarding of vulnerable adult training and mandatory training. New staff need to be monitored through induction to ensure they have the competences to be confident they can meet the peoples needs. Staffing levels to continue to be reviewed so that sufficient staff are consistently on duty. Fire tests must be consistent and rcorded on a weekly basis. To carry out the annual quality assurance programme to take into account the views of the people who live in the home. Care Homes for Older People Page 8 of 30 Staff comment: Staffing levels have improved but on occassions, when there is only four on duty in the morning, it can be manic. Deal with staff sickness levels, especially at weekends. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 30 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service can feel confident their care needs will be assessed and met. Evidence: The home has had various changes to the management in the last three months. A new manager and deputy manager have now been appointed. The Statement of Purpose and Service User Guide are in the process of being updated to include this information. The people who use the service and staff are fully aware of the new management structure. Two visitors spoken to at the time of this inspection said they received lots of information and support before their relative decided to come to live at the home. We looked at three residents files to evidence that the care needs assessments are completed thoroughly to include clear details of how to meet individual needs. The Care Homes for Older People Page 11 of 30 Evidence: assessments are carried out by the Manager of the home and contain sufficient detail to make sure that new residents can be confident their needs will be met. Assessment forms or care plans from the placing authority are also on file to ensure that all information is considered when the care needs assessment is being completed. The people who use the service confirm that their care needs were discussed prior to coming to live at the home. When required healthcare professionals are involved in the care and support of the people who are receiving intermediate care and rehabilitation. 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. Improvements are required in the care plans to make sure the documentation reflects the full care given and written guidelines are in place to ensure people are moved safely. The people who use the service receive benefit from sound medication procedures in place. People are treated with respect and there are ongoing improvements to ensure their dignity is upheld. Evidence: We looked at three care plans, which contained details of all aspects of health care needs. These included risk assessments identifying high dependency needs, such as nutrition, skin integrity, tissue viability, risk of falls, communication and when required the use of body maps. The plans had been reviewed monthly, however the recording of the process was not consistent, some entries were made on individual forms and Care Homes for Older People Page 13 of 30 Evidence: not on others. The review process needs to be clarified to make sure care staff can easily see where any changes have been made. Although the moving and handling risk assessments identify how many carers are required to support a person they do not give clear guidelines of how to move that person safely. There is good evidence of tracking the care of pressure sores, but not all outcomes are recorded. The plans also identify nutritional needs, for example, the need to increase or decrease dietary requirements, however, there is no information of how this is to be carried out. The care staff complete daily records to ensure that a summary of the care given is recorded, in some cases the writing could not be read clearly and the signatures could not be identified. The Operations Manager and Manager could also not read this information. The daily information must be legible with clear signatures of who was responsible for providing care that day. A requirement will be made in this report. The manager acknowledges the shortfalls in this area and will be providing additional training for staff when recording daily notes. Health care needs are monitored through the care plans and reviewed by the nursing staff on a monthly basis. There is equipment available to promote the tissue viability and protection or treatment of pressure sores. There was documented evidence for doctor, dentist, dietitian and optician visits. The home has corporate policies covering all aspects of medicine management. The medication administration record (MAR) are in good order and written entries are countersigned. Guidelines are now in place for the as and when required medication and care plans indicate that some people will show they are in pain by their body language. The staff administering the medication are registered nurses, three have received medication training updates in 2008. There is a well equipped medical storage room with a refrigerator and hand washing facilities. Medicine removed for disposal are recorded and stored appropriately. The administration of medication round takes around two hours to complete in the morning. The RGN stated that all residents receive their medication within the required time frame. There is also an additional RGN on duty from Monday to Friday, between the hours on 10 am to 4pm. Staff were seen knocking on bedroom doors before entering and supporting the people in a respectful manner. People spoken to say that staff are polite and respect their privacy. Comments form relatives at the time of the inspection are as follows: Whilst I have been in the lounge I have noticed that when some residents ask to go to the toilet they are asked to wait. Another relative comments that once he was told by a Care Homes for Older People Page 14 of 30 Evidence: member of staff that she was on a break and could not attend to his relative, but after he complained his relative was attended to straight away. This indicates that dignity is not upheld at all times and the home is working with staff to improve in this area. A recommendation will be made in this report. They have appointed a Dignity Champion to promote the peoples rights to be treaded with respect. The operations manager told us that all staff have been spoken to with regard to this issues and there will be ongoing monitoring to ensure that people are taken to the toilet promptly and at the time of their choice. 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. People living in the home are able to make choices about their daily lifestyle. They enjoy varied and nutritious balanced meals. Evidence: There is a planned activity programme in place and two co-ordinators positively encourage the people to enjoy the activities. The people who use the service confirm that there are various activities going on, including film shows, gentle exercising and board games. Forthcoming events are displayed on the notice board and the people spoke to say there is always something going on in the home. There are outings to the local super market and pub and one to one sessions with people who are unable to leave their rooms. People who use the service comment: The Activity Co-ordinator looks in every day to see if I want to join in with the activities. Sometimes I go down and enjoy the music or whatever is on. During the inspection, visitors were coming and going throughout the day. They were made welcome and offered tea or coffee. Some visited their relative in the lounge Care Homes for Older People Page 16 of 30 Evidence: while others preferred privacy and went to the persons bedroom. Visitors are offered to the opportunity to eat with their relative, either in their own rooms or in the dining room. The people who use the service say they have choice over their daily lives. They gave examples by saying how they can choose to stay in their rooms or go to the lounge, decide what they want to eat and drink and what they wish to wear. The manager needs to ensure that choice is not compromised if there is insufficient staff on duty. There is a four week menu in place and the food presented looked appetising. Feedback from the people, staff and relatives indicates that the food provided is of a good standard. The cook demonstrated her awareness of nutrition and special dietary requirements. She ensures that homemade cakes are provided for tea and drinks are readily available throughout the day. She speaks to the people daily with regard to their choices. The menu is displayed on each dining room table, with three choices available for the main meal. There are currently eight people that require assistance when eating and the home needs to review the system of transporting the food to the rooms to ensure that the food remains hot until eaten. Some of the plastic beakers were stained and the home continues to wash up by hand for a maximum of thirty people. The operations manager told us that the organisation is considering the installation of a dishwasher. A relative comments: The food is fine, very good food, they will always do individual things for my relative. There is a good choice of menu. Care Homes for Older People Page 17 of 30 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service can be confident their complaints will be listed to and they are protected from abuse. Evidence: The complaints procedure is on display in the home and the people who use the service say they have no complaints at this time. They indicated that they would speak to the staff or manager if they had any concerns. There is a complaints folder where all concerns and complaints are recorded with a record of the action taken. One relative said that she had complained previously and her concerns had been dealt with. The Commission has not received any complaints since the previous inspection. Staff feedback indicates that the new manager will deal with any issues and relatives also feel she is very approachable. People who use the service comment: I have no complaints but would complain if I needed to. I dont have any complaints and can not think of any. The manager is currently dealing with a safeguarding alert and is working with social services to resolve any issues. The majority of staff have received the protection of vulnerable adult training in 2008, however not all staff have received this training. There is an ongoing training programme and it is hoped that all staff will receive this training this year. A recommendation will be made in this report. Staff spoken to Care Homes for Older People Page 18 of 30 Evidence: showed a basic understanding of safeguarding procedures and would not hesitate to report any issues of concern. The people are receiving care from staff that have been checked to ensure they are safe to provide the service. Care Homes for Older People Page 19 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is clean and comfortable enabling the people to live in a safe well maintained environment. Evidence: The home employs a maintenance person and there is a planned programme of routine maintenance in the home. The gardens are well kept and accessible and the people confirmed that they use the gardens in the summer. The operations manager told us that she is in the process of discussing with the organisation the recommendation that additional communal space is provided. This is to ensure residents have enough communal seating and recreational space, other than in their bedrooms, to support the provision of a selection of activities, to meet individual needs. This relates to the planned conservatory identified at the last three inspections that has been put on hold. The laundry facilities are satisfactory. The home has two slucie facilities one of which has been condemed and will be replaced in the near future. Staff have been instructed to ensure that the sluice downstairs is used at all times to prevent the risk of infection. Clear guidelines are in place for the control of infection, including clinical waste. The majority of staff have received infection control training, however all staff should Care Homes for Older People Page 20 of 30 Evidence: attend this training. The home was clean and tidy and had a pleasant odour throughout. Care Homes for Older People Page 21 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels need to be consistent to ensure the people who use the service can be confident their needs will be met at all times. Recruitment procedures ensure that staff are safe to provide care to the people. The ongoing training programme will ensure that staff have the right skills to meet the peoples needs. Evidence: Staffing levels have been more stable since the previous inspection and additional nursing hours have been included in the rota. There was one occasion at the weekend, on Sunday 15th February 2009, when there were only three members of staff on duty in the afternoon. At the weekend there is only one RGN on duty and no activity coordinators to assist with the care. This level of staffing is not acceptable, as stated in the Statutory Requirement Notice as follows: The Registered Provider to ensure that there is a minimum of four care staff on duty in the home between the hours of 2.00 pm and 8.00 pm to meet the needs of the service users. The Registered Provider must ensure that the home is fully staffed at all times. On the day of the inspection we evidenced that there were four staff allocated for the afternoon shift, however one Care Homes for Older People Page 22 of 30 Evidence: member of staff was not available. The manager told us that they had tried to cover the full shift but there was no other staff available. As stated above the home is required to provide a minimum of four staff in the afternoon. The Manager contacted a permanent member of staff to complete a 4pm to 8pm shift. If permanent staff are not available to cover staff shortages, the service should contact agency staff to ensure that sufficient staff are on duty to meet the needs of the people and to comply with the Statutory Requirement Notice. Two relatives spoken to also say that there are occasions when there is not enough staff on duty. Comments as follows: Sometimes staff are short, usually in the afternoons. Sometimes during the evening they could do with more staff on duty. The people who use the service comment: There are times when there isnt enough staff on duty. Feedback from staff is as follows: Staffing levels have improved but shortages are still happening, but not as regular as before. With the appointment of the new manager and deputy, together with improvements that have already been made, we feel confident that staffing levels will be fully addressed. The manager has recruited one additional full time carer to commence duty next week and a further two posts will be advertised. Overall the home has complied with the Statutory Requirement Notice. However, due to the minor shortfalls previously mentioned and feedback from the people who use the service, relatives and staff, a recommendation will be made in this report to ensure that staffing levels are further reviewed. The level of staff in the afternoon are a minimum requirement and the manager told us that she would be looking at the total staffing hours during the day, together with shift times, with a view to improving staffing levels. During the last few months the home has been project managed, as there have been changes in the management structure. The staff team has not been stable with staff leaving and the added pressures of inducting new staff have had an impact on the staffing levels. The morale of the staff has improved since the previous inspection and although mixed comments were received with regard to staffing levels they have confidence in the new Manager that improvements will be made. There are currently over fifty per cent of staff who have achieved NVQ 2 or above and three carers currently completing the award. There is an ongoing NVQ programme to ensure that all staff have the opportunity of gaining this qualification. Care Homes for Older People Page 23 of 30 Evidence: Staff files viewed contained the appropriate checks such as Criminal Records Bureau, and Protection of Vulnerable Adult checks. All the relevant documentation is also in place to ensure that staff have been checked as safe to provide care to the people who live in the home. Training records indicate that there is an ongoing programme in place. Information from the training matrix shows some shortfalls in the provision of fire safety, food hygiene, moving and handling, health and safety and infection control. The Manager told us that all staff would be receiving fire and food hygiene training this month. Some staff still require moving and handling updates, health and safety and infection control. The manager told us that carers are now replaced when training courses take place. Staff also told us that they are able to access training courses. A number of carers are currently completing a dementia care course. Improvements have been made to the induction programme, and the home will need to continue to monitor staff competencies as they are still recruiting new staff. This will ensure that the home can be confident that staff are competent to meet the needs of the people using the service and to highlight any training needs. 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 new manager is aware of the improvements required in the home. Improvements are required in the quality assurance programme to make sure the people who use the service have their views taken into account to influence the running of the home. Health and Safety is promoted in the home to provide residents and staff with a safe environment. Evidence: The new manager commenced duties three weeks ago and has already identified areas of improvement in the home. She has vast experience as a District Nurse, holds the Registered Managers Award and was the Registered Manager of a previous home for five years. The people who use the service and staff say the home has improved since her appointment. We feel confident that she will address the requirements and Care Homes for Older People Page 25 of 30 Evidence: recommendations made in this report. The atmosphere in the home was much calmer since the previous inspection and the morale of staff has improved. The people who use the service can feel confident they will be supported with their finances. There is a sound financial system in place to safeguard their interests. They can be sure that any monies held on their behalf is appropriately stored and records maintained of all transactions. The last quality assurance was carried out in September 2007. A new programme needs to be implemented to ensure that the people who use the service have a say in how the home is run and can be involved in the decision making of their daily lives. Relatives and other stakeholders need to be included in the programme to gain feedback on how well the service is doing. A recommendation will be made in this report. There is ongoing informal quality assurance for example, the people who use the service and staff have regular meetings and some staff supervision has taken place. There is also a newsletter which is on display on the notice board. A supervision programme is in place and one member of staff confirmed that she had received supervision. The new manager has completed two supervisions since her appointment three weeks ago. RGN and care staff meetings are held on a regular basis and minutes are distributed for those who were not in attendance. The home promotes health and safety and has policy and procedures in place. Health and Safety meetings are held on a monthly basis. There is an on going programme to ensure that mandatory training is in place, however there are some shortfalls in this area. The manager stated that they are working through the induction programme to ensure that the care staff have the competencies to provide the care. Accidents and incidents are recorded appropriately and monitored through the care plan. Evidence is on file of observation forms being completed and a record in the daily notes in the care plan. The fire book was in good order, however the recording of the fire testing had not been completed for the last two weeks. The Manager must ensure that this is completed to ensure that the system is in good working order. A requirement will be made in this report. The Manager confirmed that environment and fire risk assessments are in place. Each person has a fire evacuation plan included in their care plan. Care Homes for Older People Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 30 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 7 15 To ensure the care plan 31/03/2010 provide staff with clear moving and handling guidelines. The daily records are legible and reflect the care given at that time. To ensure that the people and staff are safe when moving people. To ensure that records are clearly written to provide staff with details of what care has been provided. 2 38 12 The Registered Provider to ensure that a record of every fire test is in place. To ensure the fire alarm system is working satisfactorily. 18/02/2009 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 Care Homes for Older People Page 28 of 30 1 7 Care plans to clarify the record of review, and to ensure that outcomes of wound care is recorded. To clarify how to achieve identified outcomes, for example how to increase or decrease dietary needs. To ensure that people are treated with dignity at all times The Registered Provider to ensure that all staff receive safeguarding of vulnerable adult training. To make sure that the annual quality assurance programme is completed. 2 3 4 10 18 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 © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!