Inspection on 10/02/09 for Yew Tree Cottage Residential Home

This inspection was carried out on 10th February 2009.

CSCI found this care home to be providing an Excellent 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

Yew Tree Cottage Residential Home 20/02/08

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/03/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Yew Tree Cottage Residential Home Yew Tree Cottage Residential Home Hornsbury Hill Chard Somerset TA20 3DB     The quality rating for this care home is:   three star excellent 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: Gail Richardson     Date: 1 0 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 29 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 29 Information about the care home Name of care home: Address: Yew Tree Cottage Residential Home Yew Tree Cottage Residential Home Hornsbury Hill Chard Somerset TA20 3DB 0146064735 0146064735 sarah.ambridge@virgin.net 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) : Ambridge Estates Ltd care home 5 Number of places (if applicable): Under 65 Over 65 0 5 dementia old age, not falling within any other category Additional conditions: 5 0 The maximum number of service users who can be accommodated is 5. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Dementia (Code DE) Old age, not falling within any other category (Code OP) Date of last inspection Brief description of the care home Yew Tree Cottage is a care home offering personal care for up to 5 older people. Included in this registration the proprietor may provide personal care for older people with dementia. The home is a substantial domestic property situated on the outskirts of Chard, Somerset. There are also large, very attractive gardens offering considerable privacy to the front and the rear of the home. In the main house the accommodation consists of three single bedrooms with en-suite facilities all situated on the first floor. A stair lift is available for people with lesser mobility. On the ground floor there is a lounge, dining room/conservatory, kitchen and toilet. There is also one further ground Care Homes for Older People Page 4 of 29 Brief description of the care home floor bedroom with en suite facilities. Attached to the main house is an annex with lounge, kitchenette and twin bedroom with en-suite facilities. This facility is aimed for a more independent person or couple. The owner and manager Mrs Ambridge lives onsite. The home also provides day care for up to three people Monday to Friday. Day care facilities are not inspected under the jurisdiction of the CSCI. The registered manager has confirmed that as of the inspection date the current fee scale is 600.00 to 650.00 pounds per week unless occupying the annex which would require agreed ocupancy and fees to be negotiated. Fees do not include hairdressers, chiropody and any items identified as extra within the Statement of Purpose/ Service User Guide. Care Homes for Older People Page 5 of 29 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: three star excellent 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: This was an unannounced inspection, which took place over 1 day , 5 hours, on the 10th February 2009 by Regulation Inspector Gail Richardson. For the purposes of this inspection the term we will be used when referring to the Commission. The registered manager supplied us with an Annual Quality Assurance Assessment (AQAA) which gave us information about the home and included details of improvements made and plans for the future. A tour of the home took place and all of the bedrooms and communal areas were seen. There are five people currently residing at the home receiving personal care. There are also five people who also receive day care at the service on different days throughout Care Homes for Older People Page 6 of 29 the week. We spoke to three people who reside at the home and two people visiting for day care. We also spoke with two members of staff, one visitor and two people visiting the home who provide a service, this includes a visiting health professional. The registered manager was available throughout the inspection. As part of this inspection the inspector surveyed the opinions of a people using the service and Care Workers. 3 surveys were received from people using the service and 3 surveys from staff. Records relating to care including 3 care plans, 3 staff files, finances and health and safety records were examined The focus of this inspection visit was to inspect relevant key standards under the CSCI Inspecting for Better Lives 2 framework. This focuses on outcomes for people and measures the quality of the service under four general headings. These are, excellent, good, adequate and poor. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the care home does well: What has improved since the last inspection? The home has undertaken a program of redecoration and has purchased new reclining chairs for the people using the service . Equipment for other areas of the home including the boiler and laundry equipment has been replaced as required. Bathroom furniture and changes in sanitary-ware have been fitted to improve accessibility for people with reduced dexterity and mobility problems. The outer areas of the home continue to be developed for the enjoyment of people using the service. At the previous inspection on 20th February 2008, a requirement was made that people should not be admitted to the home unless a pre admission assessment has been completed. This requirement has been seen to be met. A further recommendation was made that all policies be reviewed and updated to reflect current practice, this was also seen to have been met. Care Homes for Older People Page 8 of 29 The previous key inspection identified that some adjustments to the homes Statement of Purpose / Service User Guide were needed to reflect the staffing arrangements for overnight care. This has been seen to have been completed with the identification that people may call for assistance in the night and that Mrs Ambridge is on call overnight. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 29 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 29 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes Service User Guide, Statement of Purpose and contract of residency ensure that prospective people can make an informed decision about the home. They are updated to reflect any changes at the home. All prospective residents receive a pre admission assessment by the Registered Manager. Evidence: The home produces a Service User Guide and Statement of Purpose. This is clearly written and gives a good range of information about the services the home provides. It includes information about the fees and the terms and conditions of residency. This enables prospective people using the service and their relatives/representatives to make an informed decision about the home. A copy of this document is available in the hallway of the home and is accessible to all. Care Homes for Older People Page 11 of 29 Evidence: The registered manager visits all prospective people and undertakes a detailed pre admission assessment. The registered manager explained that when considering admissions to the home, due to the small number of people using the service it is very important that the people are assessed carefully to ensure that the dynamic of the home will be maintained and that if possible People are like minded and will get on. We looked at one pre admission assessment of the most recent person admitted to the home, it was detailed and comprehensive. The home also accesses where available a copy of the Single Assessment Process (SAP) to support any care needs identified prior to admission. The homes AQAA (Annual Quality Assurance Audit ) told us that We undertake comprehensive pre admission assessments to see if we can meet prospective clients needs fully, followed by an acceptance/decline letter. One person told us that prior to permanent residence at the home they had stayed for a period of respite care. Contracts were examined at this inspection and contained details of terms and conditions or residency and included the fees charged for each room. Staff training indicated that staff have been sufficiently trained to meet the needs of people using the service. People at the home told us that staff were Kind and always helpful and Staff will help you with whatever you need . Care Homes for Older People Page 12 of 29 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person using the service has a care plan. The care plans provide a good level of detail to ensure that staff are aware of peoples needs and how to meet them. The plans are person centered and promote and support Independence. Staff were observed to treat people with dignity and respect at all times and people confirmed that they felt well cared for. Safe medication systems are in place to ensure the safety of people using the service. Evidence: We looked at three care plans. Each care plan contained a photograph of the person and is titled This is my life. It details who and what is important in each persons life and provides staff with detail to support their choices and preferences, this includes times to get up and retire to bed, dietary and recreational choices. Each plan has a life history to provide staff with an insight into peoples past and important events and includes favorite pets and hobbies. Care Homes for Older People Page 13 of 29 Evidence: The care plan identifies The things I am able to do, The things I would like you to help me with and What else we need to agree on. The detail recorded is person centered and specific to that persons choices and details how people like their care to be delivered. The plans talk about how the home will promote and maintain Independence and be supportive through making decisions and risk assessment within reason. People have risk assessments and a plan of care to support that risk. All areas of care identified in the National Minimum Standards are care planned and are signed by the person or their Representative. The care plans are reviewed monthly depending on the needs assessed and any short term needs are care planned as required. The care plans are reviewed with people using the service and their relatives/representitives every six months. A clear daily record is maintained for each person . There was a clear record of all visiting health care professionals visits and the outcome. We spoke with a visiting health professional who confirmed that staff were always cooperative and facilities were made available when they visited the home. The inspectors spent time observing the care being given and noted that the members of staff treated people using the service with dignity and respect at all times. They were clearly aware of peoples needs and preferences and the atmosphere was happy,caring and comfortable between staff and people using the service. On the day of the inspection people were very positive about living at the home and felt they were well cared for and involved in the decisions about their care. There are currently five ladies living at the home and the care staff are all female. There is one male employee who does not attend to care duties. The home operates an equal opportunities policy and the registered manager confirmed that should a male person be admitted would address this issue at that time. All people using the service who spoke to us were complimentary about life at the home. One person told us If I cant be at home, this is the next best thing. They also said that The staff are very kind and there is enough to do. All three surveys received from people using the service told us that staff always listen and act on what they said and that they all received the care and support they needed. We looked at the medication systems and they were well organized and managed. The local pharmacist had visited in July 2008 and recorded that the homes system was excellent. Two people self medicate some of their medications. Lockable storage and risk assessments are in place to support people to continue with this practice safely. Care Homes for Older People Page 14 of 29 Evidence: All staff have undertaken medication training and staff competence to deliver insulin has been assessed by the District Nurse and documented to support where there is an assessed need. The registered manager is recommended to ensure that all hand transcribed medications are signed and dated by two people when received to ensure a clear audit trail of medications received. Care Homes for Older People Page 15 of 29 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are able to enjoy a full and stimulating lifestyle with a variety of options to choose from. People are supported to maintain and develop family contact and links with the community. People are happy with the choices and provision of meals. Evidence: The home has sought the views of the people using the service and considered their varied interests when planning the routines of daily living and arranging activities both in the home and the community. This information is stored in detail in the persons care plan. Routines are very flexible and people can make choices in major areas of their life, people told us they could get up and retire whenever they wanted to and participation in activities is offered daily. The homes AQAA states All the residents benefit from one to one time with a member of the staff team each day. We have Holy Communion once a month. We also have Care Homes for Older People Page 16 of 29 Evidence: various people who come for daycare which encourages verbal and social interaction of both sexes. We have in-vision bird feeders which the residents enjoy watching. We celebrate birthdays and have frequent drinks and nibble evenings. We have a lot of family/friends input in regards to activities. The activities provided incorporate both indoor and outdoor activities with a pleasant and accessible garden available to all. People have easy access to the local community and transport is provided by Mr and Mrs Ambridge. On the day of inspection a hairdresser was visiting the home, however 2 people were visiting the local hairdressing salon as this was their preference. The manager has accessed specialist equipment and games for people with visual impairment to ensure that people feel included and can participate as part of a group. The home provides a selection of activities which promote the development of mental and physical agility and a small library has been started which is accessible to people using the service and their relatives. People told us that they enjoy watching certain programs together like Songs of Praise and programs about antiques. Three surveys received from people using the service told us that there are always activities to take part in. People are supported to maintain their religious preferences and a visiting clergy comes to the home to see people either individually or as a group. The manager explained that anybody with an alternative faith would be supported to continue to practice should they wish. The home supports family and personal relationships, one visitor told us that they were always made welcome and said that the home is special. Contact with the familys of people using the service is maintained in several ways which include e-mail updates and the use of internet Blogs to follow family trips and events. Outcomes for people are positive, and there is evidence that they are enjoying the life opportunities that they experience. Two people told us that they could not think of anything else that could be done to improve the way the home supports them. Meals are well balanced and nutritional and cater for varying dietary preferences of residents. The staff on duty take turns to cook the meals, however the manager is planning to employ a cook. All staff have a Basic Food Hygiene Certificate and a recent Environmental Health Visit awarded a 5 star rating. People told us that mealtimes are flexible and relaxed, we observed lunch which was served in the conservatory, staff are patient and helpful, and allow individuals the time they needed to finish their meal comfortably. Tables are well set and people appeared to enjoy a pleasant social interaction between people using the service and staff. Meals can also be taken in the persons room if this is preferred. People told us both on the day of inspection and by Care Homes for Older People Page 17 of 29 Evidence: surveys received that they enjoyed the food and that a choice was always available. One person said I have everything I need, the meals are good with a very good choice. Breakfast is available from 8am and the main meal of the day is lunch, a lighter evening meal is available from a list choice. The manager told us that all meals are home cooked and the kitchen was seen to be clean and well managed. After lunch people remained at the dining table to complete the crossword together which was also available in large print. Care Homes for Older People Page 18 of 29 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. Individuals and others associated with the home say that they are extremely satisfied with the service ,they say they feel safe and well supported. The complaints policy is clear and available to all. The home makes every effort to safeguard the people who live there including appropriate training and the implementation of policies to support abuse awareness. Evidence: There have been no complaints since Mrs Ambridge became the manager in October 2007. The complaints procedure is clear and includes the actions the manager will take and what the person can expect including a timescale for response. People and their representatives have a clear understanding of how to make a complaint and when they will get a final response. All three surveys received from people using the service and staff told us that they knew who to speak to if they were not happy and how to make a complaint. The homes AQAA states All the residents contracts contain our complaints procedure and it is also displayed in the main hallway and incorporated into the service user guide. Health professionals who visit the home and also relatives visiting the home told us that they find the management of the home approachable and would be able raise any questions with them. Care Homes for Older People Page 19 of 29 Evidence: The home does not currently have the need for an advocacy service but confirmed how they would access an independent Age Concern advocate when needed and literature about this is accessible in the front hall. Policies and procedures regarding safeguarding adults are available to staff and give them clear guidance about what action should be taken. All staff working within the home are fully trained in safeguarding adults and know how to respond in the event of an alert. Recruitment procedures support the protection of people using the service. Care Homes for Older People Page 20 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides people using the service with a well maintained and homely place to live, it is very comfortable, very clean and suited to needs of the people who live there. Evidence: The homes AQAA states, We provide a clean, comfortable, safe and flexible living environment. The Home is well decorated and maintained and all safety checks are in place. Mobility aids are provided where required. Residents are encouraged to personalize their rooms as they wish. We have large gardens which the residents are encouraged to utilize. The home is a two storey building with bedrooms available on both floors with stairlift access to the upper floor. The home is very well decorated and maintained whilst maintaining a homely feel.The home has been redecorated since the last inspection to a high standard. People are encouraged to bring personal possessions with them and all rooms are single occupancy and appeared to reflect the persons lifestyle. Handrails and adoptions including easier use taps are provided where an assessed need has been identified to support disability and promote Independence All rooms have en suite facilities and one upper floor room has a small sitting room. All rooms have radiator protectors and all hot water taps have thermostatic valve controllers to Care Homes for Older People Page 21 of 29 Evidence: prevent scalding. All upper floor windows are risk assessed and restricted where necessary to prevent the risk of falls. To the rear of the property there is a kitchen and conservatory dining room which overlook an attractively landscaped garden with access for all people. The kitchen is an open style and people using the service are welcome to assist with some cooking tasks. The hot water outlet is in excess of 43 degrees and appropriate risk assessment and signage is recommended to reduce any risks of scalds to people using the service. All communal areas are welcoming and personal and the lounge has a large open log fire. Electric reclining chairs are available for each person using the service. All areas of the home were very clean and no malodour were noted in any areas. All staff have received appropriate training in infection control and suitable hand washing facilities and protective clothing is available should it be needed. A visiting health professional told us that there was Always hand washing facilities available with clean towels and hot water. All three surveys received from people using the service said the home was always clean and fresh. The housekeeper has completed an NVQ in housekeeping and the standard of hygiene is a credit to the home. A small laundry is available and new laundry equipment has been purchased. Staff undertake the laundry and people using the service appeared well dressed and their clothes well maintained. Care Homes for Older People Page 22 of 29 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. The home employs enough staff to meet the needs of the people using the service and to ensure the safety, comfort and maintenance of the premises. People benefit from having trained staff that have a good understanding of their needs. Recruitment procedures are in place to protect the people using the service. Evidence: The registered manager/provider is Mrs Sarah Ambridge and she lives on the premises.The home also employs 3 other carers and a maintenance person. The home has full occupancy and staffing levels are routinely Mrs and Mr Ambridge and one other carer each day.Three staff surveys told us that they felt there were enough staff to meet the needs of people using the service. There is no waking staff as people living at the home have minimal care needs and nobody requires any care overnight. This is clarified within the homes Statement of Purpose/Service User Guide, Mrs Ambridge is on call each night for emergencies between 9pm and 08:30am. All staff with one exception have undertaken an NVQ in Care and Mrs Ambridge has completed the NVQ Registered Managers Award. All staff have recently undertaken training in Dementia Care and training in all mandatory areas has been undertaken by all staff to ensure that they can support the needs of people using the service. All Care Homes for Older People Page 23 of 29 Evidence: three staff surveys received said that the induction received had covered all aspects of their job and that training is ongoing. The home has recruited one new staff since the last inspection and has a stable and consistent staff team who know the people using the service well. The manager has recently undertaken recruitment for 2 further staff but this process is not yet complete and so cannot be fully assessed.The manager explained that she is is highly selective, with the recruitment of the right person for the job being more important to the filling of a vacancy. The application form was noted to not include the Rehabilitation of Offenders Act declaration. This is recommended to be added to the application form to ensure that the manager has a clear indication of the applicants history to enable protection of people using the service. People using the service, relatives and visiting health professionals were all complementary about the staff , they told us that they are Kind, welcoming and approachable, nothing is too much trouble. Care Homes for Older People Page 24 of 29 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is managed to promote peoples independence and peoples health and safety. The management of people using the service monies is well managed and all records are maintained in line with the Data Protection Act. Evidence: Mrs Ambridge is a trained nurse who has also completed the Registered Managers Award. She has owned/managed the home since September 2007 and has shown a consistently high standard of service delivery with routine auditing of the service with an action plan in place to address any shortfalls observed. The home provided us than an AQAA which provided us with details of how the home has developed and the managers plans for the future. One staff member told us that Sarah is a very supportive and active manager. The way the home is run shows an understanding of peoples needs in respect of their health, emotional and spiritual wellbeing and lifestyle preferences. People tell us that Care Homes for Older People Page 25 of 29 Evidence: all areas of their care are met and that they feel part of the homes community. One person told us that Sarah visits me everyday to see if there is anything I need. Quality assurance takes place with questionnaires being provided for all people using the service and their Representatives and the home actions any suggestions . The manager spends time each day with each resident and so has a daily monitoring of any issues in the home. Staff surveys and staff spoken with told us they were confident in the management of the home. Supervision of staff is ongoing and the manager is planning to develop and more structured way of recording the supervision interactions with staff. This will enable a clear audit trail of discussions and promote development of good practice for staff. All three staff surveys told us that they regularly had discussions with the manager. All policies and procedures have been updated to reflect changes in practice and the manager confirmed that they are regularly reviewed. Accident records are maintained and audited and reflect the information stored in peoples daily records. Records stored at the home are stored securely and in line with the Data Protection Act. Staff are aware of the need for security of confidential documentation and all records are maintained individually. Personal monies can be stored by the home and a record maintained of all deposits and withdrawals. These records were noted to be correct and clear audit systems are in place. The records relating to health and safety were seen, these were all up to date and reflected that all equipment is serviced as required and regular maintenance is ongoing with the maintenance staff having completed the PAT testing certificate. Care Homes for Older People Page 26 of 29 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 29 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 8 The registered manager is recommended to ensure that all hand transcribed medications are signed and dated by two people when received to ensure a clear audit path of medications received. The registered manager is recommended to risk assess the hot water outlet in the kitchen and staff toilet and provide appropriate action or signage to prevent the risk of scalds to people using the service and staff. The registered manager is recommended to include the Rehabilitation of Offenders Act declaration on the staff application form to ensure that a full history is made available to protect the people using the service. 2 26 3 30 Care Homes for Older People Page 28 of 29 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. 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