Care Home: Allendale House

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What the care home does well People in the home are provided with a warm, safe and comfortable place to live that welcomes visitors and makes them feel at home. The home is clean and staff work hard to make sure the building is odour free. The home is welcoming and has a relaxed atmosphere. People living there said they are happy with their bedrooms and can bring in their own possessions, making it feel more like home. People being cared for have good access to professional medical staff and are able to access external services such as dentists, opticians, physiotherapists, chiropody and dieticians, so their health is looked after and they are kept well. What has improved since the last inspection? The manager has worked hard to meet requirements and recommendations from the February 2007 report, this has been commented on throughout this report. What the care home could do better: The way that the home carries out employment checks on people wishing to start work in the home must get better. The manager must make sure that all police checks are completed before individuals start working in the home. We would like to thank everyone who completed a survey or spoke to us during this visit. Your comments are very important to us and ensure this report includes the views of people who use the service or work within it. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Allendale House 21 George Street Hedon Hull East Riding Of Yorks HU12 8JH     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: Eileen Engelmann     Date: 1 9 0 1 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. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: · · · · Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 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: Allendale House 21 George Street Hedon Hull East Riding Of Yorks HU12 8JH 01482898379 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Shirley Ann Fletcher Type of registration: Number of places registered: Mr Eustace Nanayakkara care home 20 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 20 The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE(E) Date of last inspection Brief description of the care home Allendale House is located close to the centre of the market town of Hedon and within reasonable walking distance of shops, leisure and health services. It is a relatively short walk to access local public transport. The home is registered for 20 people in the categories of older people and older people with dementia. The home does not provide specialist or nursing care. Should such care be required on a short-term basis then it Care Homes for Older People Page 4 of 29 Over 65 20 20 0 0 Brief description of the care home would be provided by the community healthcare services. The accommodation comprises of 18 single rooms and 1 double bedroom. Five of the single rooms have an en-suite toilet. The home has two floors with access by a chair lift to the upper floor. There is a lounge, which extends to a conservatory dining area and a separate sitting area within the home. The home is now a non-smoking premises. There is a garden area to the rear, which is accessible to people with mobility problems via ramps. 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: 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: Information has been gathered from a number of different sources over the past 23 months since the service had its last key visit from the Commission for Social Care Inspection, this has been analysed and used with information from this visit to reach the outcomes of this report. In May 2008 we completed an Annual Service Review (ASR). An ASR is part of our regulatory activity and is an assessment of our current knowledge of a service rather than an inspection. The published review is a result of the assessment and does not come from our power to enter and inspect a service. This unannounced visit was carried out with the manager, staff and people using the Care Homes for Older People Page 6 of 29 service. The visit took place over 1 day and included a tour of the premises, examination of staff and peoples files, and records relating to the service. Informal chats with a people living in the home took place during this visit; their comments have been included in this report. Questionnaires were sent out to a selection of people living in the home and staff. Their written response to these was adequate. We received 2 from staff (40 ) and 5 from people using the service (50 ). The manager completed an Annual Quality Assurance Assessment and returned this to us within the given timescale. We recieved one formal complaint around medication issues in July 2008. In response to this we carried out an unannounced inspection and found no evidence to support the complaint. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 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 9 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People wanting to use the service undergo a needs assessment and are given sufficient information about the home and its facilities prior to admission, to enable them to be confident that their needs can be met. Evidence: The people we spoke to said they received sufficient information to make an informed choice about the service before accepting the placement offer. These individuals have also received a contract/statement of terms and conditions from the home. Each person has his or her own individual file and the funding authority or the home, before a placement is offered to the individual, completes a need assessment. The home develops a care plan from the assessments, identifying the individuals problems, needs and abilities using the information gathered from the person and their family. We looked in-depth at the care and records for four individuals as part of our Care Homes for Older People Page 10 of 29 Evidence: inspection process. Discussion with the manager indicated she goes out to assess individuals who have expressed an interest in coming into the home, and each person is given information about the service and life in the home. Staff members on duty were knowledgeable about the needs of each person they looked after and had a good understanding of the care given on a daily basis. Discussion with two people showed that they were satisfied with the care they receive and have a good relationship with the staff. Information from the Annual Quality Assurance Assessment and discussion with the manager and people living in the home indicates that the majority of people using the service are of White/British nationality, however the home does have people from other European countries. Checks of the staffing rotas and observation of the service showed that the staff group are all White/British. People using the service are unable to make a choice of staff gender when deciding whom they would like to deliver their care, as the home has no male care staff due to a lack of suitable applicants. The manager said that she would discuss this with people wanting to use the service during the assessment process. Information from the training files and training matrix indicates that the majority of staff are up to date with their basic mandatory safe working practice training, or they are booked onto training in 2009. The home is registered with us to accept placements for people with dementia and the manager is aware of the need to have robust staff training around dementia and challenging behaviour to ensure the staff are able to meet peoples needs. The staff-training matrix given to us on this visit (January 2009) shows that the majority of staff accessed dementia training during 2008. The home does not have any intermediate care beds and therefore standard six does not apply to this service. Care Homes for Older People Page 11 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, personal and social care needs of people living in the home are being met by the service and staff. Evidence: Information from this visit indicates that the people who spoke to us are on the whole satisfied that the staff give appropriate support and care to those living in the home. People said they are able to make their own decisions about their daily lives most of the time; that staff treat them well and listen and act on what they say. One person told us the staff are lovely, they have time to talk to you and nothing is too much trouble. At the last key visit in February 2007 a requirement was made that the service users plan must be kept under review Checks at this visit found the requirement is met. Discussion with the manager indicates that the care plan format has been reviewed and up dated in December 2008 to January 2009 and this is part of a six monthly Care Homes for Older People Page 12 of 29 Evidence: ongoing process. Care staff are evaluating the plans on a monthly basis. The care of four people was looked at in depth during this visit and included checking of their personal care plans. The content of the plans is easy to follow and on the whole completed to an acceptable standard. It was discussed with the manager that there are a few areas in the care plans that staff need to take more time over and these include Where an individual has bed rails in place a risk assessment must be completed. This was not in place for one person whose care we looked at. Discussion with the manager indicated that this is not usual practise and we were assured the risk assessment would be done immediately. Information around equality and divesity issues such as religion, sexuality, wishes around death and dying and choice of staff for giving care should be clearly identified in the care plan. There is a yearly formal review process for the care of people using the service with the funding authorities and family (where the person receiving care consents to this). Minutes of the reviews are kept in the individuals care plan. Positive aspects of the plans include risk assessments for moving and handling, nutrition, pressure sore development, falls and individual choices regarding activities of daily living. Weights are recorded monthly and there is evidence that staff are contacting outside health professionals for advice and visits were needed. People said that they have good access to their GPs, chiropody, dentist and optician services, with records of their visits being written into their care plans. They all have access to outpatient appointments at the hospital and records show that they have an escort from the home if wished. Comments from the people using the service indicate they are satisfied with the level of medical support given to them. We made an unannounced visit to the home in July 2008 in response to a complaint that medication in the home was being administered by unqualified staff. Investigation into the complaint found that it was not proven and all staff who were responsible for the giving out of medication had recieved appropriate training. Medication is provided by a local pharmacy and is supplied in a pop-out system with additional boxes and bottles of medication were necessary. Checks of this system showed the records are up to date and accurate. We recommended that where staff are hand writing medication onto the sheets (transcribing), there should be two staff signing the entry to indicate they have both Care Homes for Older People Page 13 of 29 Evidence: witnessed that the information on the sheet (name of medication, strength and administration methods) is correct. At least one person in the home has Temazepam prescribed for them. This was stored in a locked box in the medication area. It is now a legal requirement for all care homes to have a controlled drugs cabinet. Peoples comments show they are satisfied with the care and support offered by the staff. Chats with people using the service revealed that they are happy with the way in which personal care is given at the home, and they feel that the staff respect their wishes and choices regarding privacy and dignity. Observation of the service showed there is good interaction between the staff and people, with friendly and supportive care practices being used to assist people in their daily lives. Care Homes for Older People Page 14 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with choice and diversity in the meals and activities provided by the home. Individual wishes and needs are catered for and people have the option of where, when and how they participate in both eating and leisure activities. Evidence: The home employs an activities organiser for three days a week (Tuesday, Wednesday and Thursday) and she is responsible for planning and organising the formal weekly programme of social events. Last weeks written programme indicates people took part in a Quiz, board games, bingo and carpet skittles. The manager told us the home has recently purchased a kareoke machine for people to use as part of the weekly entertainment sessions. The home has outside entertainers booked on a regular basis and the week we visited an organist was due to play on Friday afternoon. The mobile library visits on a regular basis and there are a range of large print books and audiotapes made available to those who enjoy reading/listening to literature. Comments from our surveys were that I like to join in and think the activities are a Care Homes for Older People Page 15 of 29 Evidence: good thing and I enjoy the quizzes and sing a longs. Records are kept of all the social interactions going on in the home and evidence seen at this visit indicates that people are encouraged to celebrate Christian events such as Birthdays, Easter and Christmas. People have access to the local churches and home visits can be arranged by request. Discussion with the people living in the home indicates that they have good contact with their families and friends. Everyone said they were able to see visitors in the lounge or in their own room and they could go out of the home with family. Visitors were seen coming and going during the day, staff were observed making them welcome and there clearly was a good relationship between all parties. We spoke to one visitor who told us I come to see my friend at least three times a week, I am always made welcome and offered a drink by the staff. People spoken to were well aware of their rights and said that they had family members who acted on their behalf and took care of their finances. There is some information and advice on advocacy and this is on display in the entrance hall. Discussion with the manager indicated that some staff have had equality and diversity training through their NVQ work, but we would recommend that the home ensures all staff have access to training around current legislation in equality, diversity and disability matters. The registered person should make sure that staff have sufficient knowledge about human rights legislation, so they understand individual rights within the care home and out in the community. People are able to eat their meals in their own bedrooms, the lounge or in the dining rooms. There was only one choice of main meal at lunch time, but talking with the manager and people using the service it is obvious that alternatives are available if requested. One person told us I am fussy about my food, but I always get what I like because the staff always ask me what I want to eat. There was no sign of any printed menus in the dining room, but a menu board is clearly on display in the entrance hall showing the days meal choices. Care Homes for Older People Page 16 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. The home has a satisfactory complaints system with some evidence that peoples views are listened to and acted upon. Evidence: The home has a complaints policy and procedure that is included in the statement of purpose and service user guide. It is also on display within the home and the survey responses from people using the service showed individuals have a clear understanding about how to make their views and opinions heard. People told us that we would talk to the staff if we had any problems. The home has developed a niggles and grumbles book since the last key visit in February 2007 in response to a recommendation made in the report from that visit. However, some of the information in this book is detailed and we recommended that the manager use the complaints form for most issues and only used the book for very minor things that staff usually deal with on a day to day basis. We recieved one formal complaint in the last twelve months and this was about medication (see health section of this report). We visited the home to investigate the issues and found that no further action was necessary. Safeguarding issues and outcomes areas such as health care, staff supervision, staff Care Homes for Older People Page 17 of 29 Evidence: training, complaints and safeguarding of adults have been looked at as part of this visit. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint and management of peoples money and financial affairs. The staff on duty displayed a good understanding of the safeguarding of adults procedure. They are confident about reporting any concerns and certain that any allegations would be followed up promptly and the correct action taken. Information from the staff training records and discussion with the manager indicated that staff have recieved safeguarding training from the local council in 2007, and this is discussed and reviewed during supervision with the staff. We recommend as good practise that all new staff undergo formal safeguarding of adults training and that a refresher session is attended each year. Discussion with the people using the service indicates that they feel safe within the home and are confident that staff would help them if they had any concerns or problems. Care Homes for Older People Page 18 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of environment within the home is good, providing people with a comfortable and homely place to live. Evidence: We walked around the building and found it satisfactory and suitable to meet the needs of the people using the service. The home has an ongoing maintenance and refurbishment programme and the environment is clean, comfortable and homely. Since our last visit in February 2007 the four bedroom extension has been completed and the home re-registered for twenty beds. This was a requirement in the February 2007 report and has been met. Since the last visit in 2007 the managers office has moved into a small space off the dining room; whilst this is an improvement from the office being in the dining room, the office space remains cramped and is not sufficient to accommodate the filing cabinets for the paperwork. The cabinets remain in the dining room and encroach onto the communal space for people using the service. Water temperatures are tested by the manager on a regular basis and these remain within the recommended guidelines. This was a requirement in the 2007 report and Care Homes for Older People Page 19 of 29 Evidence: has been met. Discussion with the deputy manager indicated that the damaged air vent in the dry food store mentioned in the 2007 report was repaired soon after that visit. The requirement in the report is now met. Walking around the home we noticed two areas that need action taking, these were :The upstairs bath in the new wing has a crack in the floor of the bath, it has had a temporary repair made, but we recommend that the bath be replaced as soon as possible. Bedroom 9 is currently empty and we found that the double doors in the room are rotten at the base with some wood missing and gaps showing to the outside. These doors need repairing or replacing as soon as possible. The laundry facilities in the home remain cramped and only just adequate for the home. This has been noted in previous reports, but is an ongoing problem. Laundry is carried out in a small L shaped room with one washer for nineteen people. Discussion with the staff indicated that they are able to get the washing and drying done within a reasonable timescale. Since the last visit in 2007 an automatic door closer linked to the fire alarm has been fitted to the laundry door. The requirement made in the 2007 report has been met. We found that a tumble dryer has been relocated to a small room downstairs, again space is at a premium and staff are managing with what facilities they have got. Discussions during this visit indicate that people using the service are satisfied with the laundry service provided by the home. Infection control policies and procedures are in place, and staff have access to good supplies of aprons and gloves for use in personal care. Checks of the staff training files showed that individuals attended infection control training in 2007. We recommend that the manager ensures that refreshers of this training are done yearly. Care Homes for Older People Page 20 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff recruitment practises are not robust and do not protect the health, safety and well being of those people using the service. Evidence: People and staff who responded to our surveys told us that there is usually a good level of staff on duty within the home. Individuals told us that we dont wait long for staff to answer the call bell and they are always available when we need them. At the time of this visit (January 2009) the manager informed us that there was 17 people in the home. Copies of the staffing rotas supplied to us by the manager during our visit showed that during the day time there are three care staff on duty and at night there are two staff on duty. Using this information we checked the Residential Staffing Forum guidance and found the home is meeting the recommended guidelines. 50 of care staff at the home have an NVQ 2 or above in care and new starters complete an induction which meets Skills for Care criteria. The home has a mandatory staff training programme in place and information from the staff training matrix indicates that the majority of the staff are up to date with this or are booked onto refresher training for 2009. Good practise recommendations have been made within this report where we felt that training could be strenghtened. Care Homes for Older People Page 21 of 29 Evidence: The home has an equal opportunities policy and procedure. Information from the staff personnel and training records and discussion with the manager, shows that that this is promoted when employing new staff and throughout the working practices of the home. At the last visit to this home in February 2007 a requirement was made that before employing anyone to work in the care home a Criminal Records Bureau (CRB) application must be made, and a POVA first check and two satisfactory references obtained. The member of staff must then only work under supervision until the results of the CRB check are recieved. At this visit in January 2009 we looked at three staff files and found the above requirement has not been met. The home has a system in place for sending for CRB applications and POVA first checks through an umbrella body (external company), however for two people employed in 2008 this system failed and their POVA first checks were not recieved until six months after they started work. Their CRB applications have still not been processed almost seven months after they were sent off. Whilst it is not acceptable to employ individuals until the checks are completed, we recognise the fact that the home has tried to meet the requirement but was failed by the system. The requirement around employment checks will remain on this report and we spent time explaining to the manager that failure to meet this requirement within the given timescales could lead to enforcement action being taken against the home. Care Homes for Older People Page 22 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management of the home is satisfactory overall and the home regularly reviews aspects of its performance through a good programme of audits and consultations, which includes seeking the views of people using the service, staff and relatives. Evidence: The registered manager is Shirley Ann Fletcher, she is suitably qualified and experienced to run the home. People and staff told us in the surveys that the manager is very approachable, supportive and available to talk to when needed. The home has achieved the local councils quality assurance award (QDS part 1) and regularly checks its service to ensure it is still meeting the needs of the people living in the home. Policies and procedures within the home have been reviewed and updated to meet current legislation and good practice advice from the Department of Health, Care Homes for Older People Page 23 of 29 Evidence: local/health authorities and specialist/professional organisations. In the February 2007 report a requirement was made that the registered person must make monthly unannounced visits to the home and prepare a report on the conduct of the home. Discussion with the manager indicated that due to ill health the provider has been unable to visit monthly, but does communicate on the telephone on a regular basis. The requirement will remain on this report. Feedback is sought from the people living in the home and relatives through regular satisfaction questionnaires, and the manager has produced a development report as part of this process to highlight where the service is going and/or indicate how the management team is addressing any shortfalls in the service. Meetings for people using the service are held every three months, but the manager has found these are poorly attended. To aid relatives in keeping up to date with things taking place in the home, the manager has produced a Families Information Sheet. Staff have meetings with the manager and everyone is encouraged to join in with discussions and voice their opinions. People and staff agreed that they are able to express ideas; criticisms and concerns without prejudice and the management team will take action where necessary to bring about positive change. Checks of the finance systems within the home found that handwritten records are kept for peoples personal allowances; the manager on a daily basis up dates these. Information from the Annual Quality Assurance Assessment indicates the majority of people have their families looking after their financial affairs, and checks of the system show their relatives top up the persons individual allowance account on a regular basis. People who have asked the home to look after their personal allowances are able to access their money on request, and receipts are kept for any transactions. All monies are kept safe and secure within the home and only the manager or the deputy manager has access to the funds. Maintenance certificates are in place and up to date for all the utilities and equipment within the building. Accident books are filled in appropriately and regulation 37 reports completed and sent on to the Commission where appropriate. Staff have received training in safe working practices and the manager has completed generic risk assessments for a safe environment within the home. Risk assessments were seen regarding fire, moving and handling and daily activities of living. Care Homes for Older People Page 24 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 25 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 1 9 13 A controlled drugs cabinet that meets legal requirements must be obtained. This will make sure that the home is complying with the new legislation for storing controlled drugs to make sure they are secure. 01/05/2009 2 19 23 The registered person must ensure that action is taken to repair/replace the upstairs bath in the new wing, and the double doors in room 9. So people can be satisfied that the facilities they use within the home are being maintained to a high standard and are fit for purpose. 01/06/2009 3 29 19 The registered person must ensure that robust recruitment checks for Pova first and CRBs are in place and actioned before 01/05/2009 Care Homes for Older People Page 26 of 29 individuals start work in the home. This will minimise the risk to people living in the home, by ensuring staff who work there are fit to work with vulnerable people. 4 33 26 The registered person must make monthly unannounced visits to the home and prepare a report on the conduct of the home. The registered person is responsible for the provision of the service and must make sure it meets the aims and objectives set out in the statement of purpose, and meets the needs of the people using the service. 01/06/2009 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 1 7 The manager should make sure that all people who have bed rails in place, have a risk assessment completed that is reviewed on a regular basis and has the consent of the person or their representative in writing. The manager should make sure that the care plans include specific equality and diversity information about each person, so individualised care can be provided by the staff to meet their needs. The manager should make sure that where staff are hand writing medication onto the sheets (transcribing), there are two staff signing the entry to indicate they have both witnessed that the information on the sheet (name of medication, strength and administration methods) is correct. The registered person should make sure that staff have sufficient knowledge about human rights legislation, so Page 27 of 29 2 7 3 9 4 14 Care Homes for Older People they understand individual rights within the care home and out in the community. 5 18 The manager should ensure that all new staff undergo formal safeguarding of adults training and that all staff attend a refresher session each year. The manager should ensure that infection control refresher training is made available to all staff on a yearly basis. The registered person should consider how the laundry facilities within the home can be improved, so that staff are working in a better environment that meets the demand of the service. 6 7 26 26 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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