Care Home: Ashleigh House Care Home

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What the care home does well The home has processes in place for assessing potential new people, with services being offered to only those individuals whose needs can be met. People who use the service are offered a good provision of health care and personal support by the home. People who use the service benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect individuals in the event of an allegation of abuse. The home has a staff team that have the necessary skills, training and experience to the meet the needs of the people who use the service. What has improved since the last inspection? Staff have received training in medication administration in order to ensure that errors associated with medication are minimised. In order to ensure that the risk of cross infection is reduced, a new sluicing washing machine has been installed. Staff files have been updated to include all items required under the Care Homes Regulations 2001, in order to further safeguard people who use the service. What the care home could do better: In order to ensure that potential individuals to be accommodated at the home are appropriately assessed, pre admission assessments require updating to include the involvement of the individual and/or their representative, as well as where the assessment was conducted. Where individuals are not involved this must also be recorded. Care plans must be devised with the involvement of the individual and/or their representative, in order to ensure that they have their rights and choices recognised. Where individuals are not involved this must also be recorded. In order to ensure the holistic needs of people accommodated can be met, risk assessments and care plans must be developed consistently. Care plans must also be reviewed and updated on a consistent monthly basis and the reviews are conducted with the involvement of the individual and/or their representative. In order to further ensure the privacy and dignity of the people who use the service, bathroom doors must be fitted with appropriate locking devices. In order to ensure that activities are wide ranging and stimulating, consideration must be given to the comments made by staff and people who use the service, in relation to activities and the frequency with which they are provided. The ongoing refurbishment plan must be effective and render all areas of the home fit for purpose and decorated to a high standard, whilst fixtures and fittings must be updated according to need, whilst all fittings must be in a good state of repair; in order to ensure that people who use the service live in a homely environment. The cleaning programme must be effective and allow for the home to be maintained in a clean and fresh manner, in order to further promote a homely environment. There must be appropriate hand washing facilities available for use at all times, in order to reduce the risk of cross infection. In order to ensure that the home is run in accordance with the wishes of people who use the service, a report must be published annually, which details the findings of Quality Assurance questionnaires. Regulation 26 Provider Visit Reports must be of good quality and give a true reflection of the care, services and environment provided. In order to further safeguard individuals finances, all personal allowance accounts held for individuals must be accurate and clear records of all transactions must be maintained. In order to ensure the health and safety of staff and people who use the service, individuals who smoke, must smoke in the designated smoking area at all times. Recommendation for good practice were also made: consideration should be given to employing a weekend cleaner, in order to keep the home clean a fresh everyday of the week. The AQAA, training matrix and staff files are cross referenced to ensure that training attended by staff is clearly and consistently recorded. Key inspection report Care homes for older people Name: Address: Ashleigh House Care Home 18-20 Devon Drive Sherwood Nottingham NG5 2EN     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Rebecca Shewan     Date: 2 0 0 4 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 32 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Ashleigh House Care Home 18-20 Devon Drive Sherwood Nottingham NG5 2EN 01159691165 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mr William Scott Name of registered manager (if applicable) Mrs Eileen Joyce Hester Type of registration: Number of places registered: care home 19 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Ashleigh House is a care home providing personal care and accommodation for 19 older people. The home is owned by William Scott, which is run as a family business. The home is located in a residential area of Sherwood, close to shops, pubs, the post office and other amenities. Opened in 1987 it consists of two converted terraced houses with a purpose built extension. Fifteen of the home s bedrooms are single occupancy. One of the bedrooms has en-suite facilities. Bedrooms are located over three floors, with a passenger lift making each floor accessible. The home has a small, enclosed garden and a small car park. The fees for the service are GBP336 to GBP 380, per week with additional charges made for hairdressing and chiropody. Care Homes for Older People Page 4 of 32 0 Over 65 19 Brief description of the care home Potential new people find out about the service via the internet, CQC reports, by contacting the home direct, by Placing Authorities and Health Social Care Professionals. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced inspection took place during the morning and afternoon of the 20th April 2010. Incident reports and the homes Annual Quality Assurance Assessment (AQAA), held by the Care Quality Commission, were read before the inspection. The AQAA that was sent to us by the service is a self-assessment, which focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. The inspection of the home took six and a quarter hours. A tour of the home was undertaken and the Registered Manager, two staff and four people who use the service were spoken with. The CQC also conducted surveys of staff and people who use the service. The response to which were generally positive. Comments made have been incorporated in to the report. Care Homes for Older People Page 6 of 32 The main method of inspection we use is called case tracking, which involves us choosing three people who live at the service and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Records such as care plans, staff files and medication records were also viewed. Seventeen people were accommodated at the home at the time of the inspection. NB: That The Care Quality Commission (CQC) is referred to as we throughout this report. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: In order to ensure that potential individuals to be accommodated at the home are appropriately assessed, pre admission assessments require updating to include the involvement of the individual and/or their representative, as well as where the assessment was conducted. Where individuals are not involved this must also be recorded. Care plans must be devised with the involvement of the individual and/or their representative, in order to ensure that they have their rights and choices recognised. Where individuals are not involved this must also be recorded. In order to ensure the holistic needs of people accommodated can be met, risk assessments and care plans must be developed consistently. Care plans must also be reviewed and updated on a consistent monthly basis and the reviews are conducted with the involvement of the individual and/or their representative. In order to further ensure the privacy and dignity of the people who use the service, bathroom doors must be fitted with appropriate locking devices. In order to ensure that activities are wide ranging and stimulating, consideration must be given to the comments made by staff and people who use the service, in relation to activities and the frequency with which they are provided. The ongoing refurbishment plan must be effective and render all areas of the home fit for purpose and decorated to a high standard, whilst fixtures and fittings must be Care Homes for Older People Page 8 of 32 updated according to need, whilst all fittings must be in a good state of repair; in order to ensure that people who use the service live in a homely environment. The cleaning programme must be effective and allow for the home to be maintained in a clean and fresh manner, in order to further promote a homely environment. There must be appropriate hand washing facilities available for use at all times, in order to reduce the risk of cross infection. In order to ensure that the home is run in accordance with the wishes of people who use the service, a report must be published annually, which details the findings of Quality Assurance questionnaires. Regulation 26 Provider Visit Reports must be of good quality and give a true reflection of the care, services and environment provided. In order to further safeguard individuals finances, all personal allowance accounts held for individuals must be accurate and clear records of all transactions must be maintained. In order to ensure the health and safety of staff and people who use the service, individuals who smoke, must smoke in the designated smoking area at all times. Recommendation for good practice were also made: consideration should be given to employing a weekend cleaner, in order to keep the home clean a fresh everyday of the week. The AQAA, training matrix and staff files are cross referenced to ensure that training attended by staff is clearly and consistently recorded. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 32 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 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has processes in place for assessing potential new people with services being offered to only those individuals whose needs can be met. Evidence: From the records viewed we observed that the homes Registered Manager or one of her Senior Carers, carry out pre- admission assessments. We observed that copies of care management assessments from the placing authority are obtained, where these exist. The Registered Manager reported that she addresses any issues, which are highlighted within this assessment. We observed that documented records are maintained of all correspondence with the placing authority. Records inspected showed that pre- admission assessments are carried out on all new and potential people. Documentation relating to the most recent admissions to home were viewed; two of the three sampled were found to have been completed fully. We Care Homes for Older People Page 11 of 32 Evidence: observed that of the three assessments sampled, there was no evidence included in of the assessment having been conducted with the involvement of the individual and/or their representatives (where applicable). We also observed that two of three pre admission assessments sampled, that the did not provide information as to where the assessment was conducted. Intermediate care is not provided by this home. Care Homes for Older People Page 12 of 32 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are in place but do not provide clear guidance for staff in relation to all of the individuals needs. People who use the service are offered a good provision of health care and personal support by the home. Medication procedures ensure that medication are stored and administered safely. Evidence: From care files observed we evidenced that each individual has a care plan but the practice of involving the person who uses the service, and/or their representative, in the development and review of the plan was not evident. The plan includes information necessary to deliver the persons care but were not person centred. We observed that care plans were not consistently reviewed and updated as required by the National Minimum Standards. People who use the service were not always aware that they have a care plan. Records observed (such as care plans and Quality Care Homes for Older People Page 13 of 32 Evidence: Assurance questionnaires) highlighted that individuals are not actively encouraged to be involved in its review or development. We observed from records that risk assessments are completed but these are also inconsistently reviewed. We observed that one care plan contained an assessment on nutrition that stated that the individual had lost weight over a period of one month, the reason entered stated loss of appetite. We observed that there were no more entries following this (a period of three months)and there was no care plan in place for nutritional needs. We observed from care plans viewed that none of these sampled contained evidence of the individual having been assessed for Deprivation of Liberties or for mental capacity. The Registered Manager confirmed that she had attended training in these subjects and had planned to assess each individual over the next two months. We observed that a risk assessment for continence stated that the individual was incontinent frequently during the day and night and was at risk of a red bottom. We observed that the assessment was not dated or signed and there were no care plans in place for the individuals continence or tissue viability needs. Daily care records were also viewed and we observed that these were not reflective of the care plan and included comments such as spent the day knitting and watching TV, (Name) was up at start of shift, was served all meals in their room, meds taken, (Name) is fine, (Name) walked to commode and back with no bother. From discussions with the Registered Manager, we observed that people who use the service are registered with one of two local Health practises and have access to seven GPs. District Nurses, provide continence advice and attend the home as needed and are accessed directly by the staff of the home. Domiciliary Opticians attend the home and private appointments to local opticians are also supported. Access to physiotherapy, Occupational Therapy and the Dietician are sourced via the GP. Audiology appointments are arranged via The Ropewalk centre, based in the centre of Nottingham City. The home has a Chiropodist who attends the home every six weeks and as required. The home has good links to the Community Mental Health Team. We observed that the home has good procedures in place for the monitoring and recording of all drugs administered and those entering and leaving the home. We Care Homes for Older People Page 14 of 32 Evidence: viewed the stores for medication and these were found to be maintained in a clean and orderly manner. Records of medication fridge temperatures were viewed and we observed that these are now recorded on a consistent daily basis. We observed that controlled drugs held in the home are appropriately stored and accounted for. It was observed that individuals bedroom doors were knocked before staff entered them. We observed that the privacy and dignity of people who use the service is not always protected; a number of bathroom doors do not lock properly or have locks that are easy to adjust by the persons accommodated, on several occasions we observed people using the toilet with the door propped or left open. Care Homes for Older People Page 15 of 32 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. The home provides a limited range of recreational facilities for the people who use the service. Evidence: We observed that records are maintained of all activities attended by individuals and whether they enjoyed them or not. From records viewed and discussions with people who use the service, we observed that in house activities are limited and are not provided on a daily basis. There is no activity coordinator at the home and all activities are conducted by care staff. We observed that no activities were held on the day of the inspection. We observed from records and from discussions with the Registered Manager that Holy Communion is provided for the people accommodated. The Registered Manager reported that individuals are supported to attend the local church on a weekly basis. From records viewed and discussions with people who use the service, we observed that contact with family and friends is positively encouraged, with visitors being able to attend the home at any time and in accordance with the individuals wishes. Care Homes for Older People Page 16 of 32 Evidence: We observed that menus are planned with the input of the individuals accommodated. The Cook reported that menus are devised on a daily basis and that all meals are home cooked with an alternative option available for each mealtime. We observed that meals can be taken in the individuals bedroom or in the communal dining room. We observed that medical, therapeutic or religious diets are provided as needed. We observed that there is a system in place for drinks and snacks to be available at all times. We observed that the meal served during the inspection was ample in quantity and attractively presented. The lunchtime meal was observed to be unhurried.Records of daily menus taken were observed and we noted that they offered a good variety. Staff and people who use the service told us Good food, lovely outings, look after us well, give us what we want, I like the staff, (the staff) Help keep me happy, feed me well and lets me go shopping, Ashleigh house could do more activities through the day and (staff could be) Given more resources to give more one to one care/activities and take care with the diversity of people that use this home. Care Homes for Older People Page 17 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service benefit from a robust and efficient complaints procedure, whilst the homes procedures, processes and staff training should protect individuals in the event of an allegation of abuse. Evidence: We observed that the home has an established complaints procedure in place. The homes AQAA and records viewed, provided evidence that the home has received no complaints in the past twelve months. People who use the service that were spoken with and survey responses, highlighted that they would know how and who to complain to. From staff files viewed we observed that both Criminal Records Bureau (CRB) and Protection of Vulnerable Adult (POVA) checks are carried out on all new and existing staff. Training records confirmed that staff have attended training in the Safeguarding of Vulnerable Adults within the last twelve months. Records sent to the CQC confirmed that there has been three Safeguarding Alerts raised in relation to the home in last twelve months. Two of these three matters have subsequently been resolved and appropriate action has been taken by the service to ensure that people who use the service are protected. Care Homes for Older People Page 18 of 32 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 poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a poor standard of internal decoration for the people who use the service, though the structural environment is suitable for its purpose. Evidence: We observed that the home provides a physical environment that meets the specific needs of the people who live there. From a tour of the premise and from discussions with the Registered Manager and staff, we evidenced that there is an ongoing maintenance programme in place, though essential maintenance is only completed when a problem has already arisen. We observed that a number of the fixtures and fittings need replacing and some of the decor requires upgrading, the poor quality of the decor and environment has a detrimental impact on the lives of the people accommodated. From records viewed we observed that The Registered Manager has sought the advice of an appropriate authority with regards to safe and hygienic sluicing practises. From Regulation 26 reports and observations made on the tour of the premises, we evidenced that a new sluicing washing machine has been installed. As previously mentioned in Daily life and Social Activities, we observed that a number of bathroom doors do not lock properly or have locks that are easy to adjust by the Care Homes for Older People Page 19 of 32 Evidence: persons accommodated. We also observed that no toilets in the home had a wall mounted toilet roll holder. All toilet rolls observed were located on the cistern. This was conveyed to the Registered Manager and by the conclusion of the inspection, new toilet holders had been purchased and fitted. Externally, we observed that the home is well maintained and the garden has been updated and the car park has been cleared. Internally, we observed that a number of areas of the home have been redecorated. The dining room has been finished to a good standard, though the recently redecorated shower room was found to have peeling paint and wallpaper on the walls and ceiling. Carpets throughout the home were observed to be threadbare. A number of bedrooms viewed had peeling wall paper or peeling paint. We observed that the home has one cleaner, who is on duty Monday to Friday. On the tour of the premise we observed that a number of the bedrooms had dirty carpets and those with laminate flooring were dusty. A number of the toilets were dirty when we arrived but had been cleaned before we left the premises, which raised concerns about how clean the home is over the weekend period. We discussed our findings with the Registered Manager, who informed us that the home has been without an industrial vacuum for a three week period. We also discussed with the Registered Manager and Registered Provider how there were areas of the home that had a malodour of urine. We observed that this was due to the poor maintenance and cleanliness of the carpets fitted throughout the home. We observed from the tour of the premise that a number of bathrooms and toilets did not contain any soap for hand washing. We conveyed this to the Registered Manager and this was rectified by the conclusion of the inspection. Staff and people who use the service told us They provide a loving, caring environment, The homes structural appearance could be better, They could let us have a nicer garden and better decoration and Better access to the garden please and do more decorating!. Care Homes for Older People Page 20 of 32 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 has a staff team that have the necessary skills and experience to the meet the needs of the people who use the service. Evidence: We observed that there is a staff rota in place, which details staff hours of working and job designations. Discussions with the Registered Manager and Registered Provider highlighted that domestic staffing cover should be reviewed to ensure that the home is always clean and up to standard. From records viewed we observed that the home has a permanent staff team of the Registered Manager, three Senior Carers, nine care staff, one cook and one Kitchen Assistant and one Domestic. From the training records viewed we observed that nine care staff are NVQ, level 2 or 3, trained in care. We observed a sample of staff recruitment files and it was evidenced that these files contain all items required under the Care Homes Regulations 2001 (as amended. We observed that the home has an Equal Opportunities policy in place and is an equal opportunities employer. Care Homes for Older People Page 21 of 32 Evidence: We observed the AQAA, staff training matrix and individual staff training files which, confirmed that Health and Safety, Safeguarding Vulnerable Adults, Food Hygiene, Fire Safety and Moving and Handling training has been conducted within the last twelve months. Though this information had to be sourced from three documents and neither document contained the exact same information. The Registered Manager reported that further training in Deprivation of Liberties, and the Mental Capacity Act, Infection Control and First Aid will be conducted in the coming months. From the records viewed we observed that additional training is also provided in other subjects that arise from changes in individuals needs. The Registered Manager confirmed that four staff had received recent updates in medication administration, records viewed supported this. Care Homes for Older People Page 22 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service do not always experience the benefits of a home that is well managed and administrated. Evidence: The Registered Manager has the required qualifications and experience to run the home. Staff and people who use the service told us that she is approachable and open to new ideas. The AQAA contains clear, relevant information that is supported by a wide range of evidence. The AQAA lets us know about changes they have made and where they still need to make improvements. From records viewed and discussions with the Registered Manager we observed that a formal quality monitoring system is in place. Questionnaires of staff, people who use the service and their relatives have been completed. We observed from these that people were generally happy, though a number of questions had been consistently left Care Homes for Older People Page 23 of 32 Evidence: blank, indicating an area of concern. We also observed the results of the questionnaire had not been analysed and there has been no report published. Regulation 26 (Provider Visit Reports) were observed to be in place, though the quality of these reports are not reflective of the situation in the home regarding care planning and the environment. From records observed we evidenced that both staff and residents meetings are held, all of which are minuted. The Registered Manager reported that the home does not take any responsibility for many of the individuals finances and most people have family, friends or representatives who protect their financial affairs. Personal Allowance accounts are maintained for many of the people who use the service, detailed accounts of which are maintained. From the accounts and procedures observed, we evidenced that two staff sign for all transactions, all monies are kept locked in a safe place and all monies are maintained in individual money bags. Of the eight accounts audited we observed that two are held for secure reasons only (as the family of the individual maintain the account), four were correct and two were found to be incorrect; one by 20 GBP and one by 8 GBP. The homes AQAA, observations made on the tour of the premises and records viewed provided evidence that fire drills, fire alarm testing and fire equipment checks, health and safety checks and water checks had been carried out. From the tour of the premise we observed that an unoccupied bedroom was being used as a smoking room. We observed that there were a large quantity of cigarette ends in the sink and the room smelt of smoke. This was reported to the Registered Manager, who investigated the matter and concluded that this could have been two people who are accommodated using the room at night time. Care Homes for Older People Page 24 of 32 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 32 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 3 14 The registered person must ensure that pre admission assessments are updated to include the involvement of the individual and/or their representative and where the assessment was conducted. Where individuals are not involved this must also be recorded. In that this will ensure that there has been appropriate consultation regarding the assessment with the individual or their representative. 20/06/2010 2 7 15 The registered person must ensure that risk assessments and care plans are developed consistently. In that this will ensure that there are appropriate care plans in place that reflect areas of risk identified. 02/06/2010 Care Homes for Older People Page 26 of 32 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 3 7 15 The Registered person must 02/06/2010 ensure that care plans are reviewed and updated on a consistent monthly basis and the reviews are conducted with the involvement of the individual and/or their representative Where individuals are not involved this must also be recorded. In that this will ensure that there has been appropriate consultation regarding the care plan review with the individual or their representative. 4 7 15 The registered person must 20/06/2010 ensure that care plans are devised with the involvement of the individual and/or their representative Where individuals are not involved this must also be recorded. In that this will ensure that there has been appropriate consultation regarding the care plan development with the individual or their representative. Care Homes for Older People Page 27 of 32 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 5 10 23 The Registered person must ensure that bathroom doors are fitted with appropriate locking devices. In that this will ensure that people who who use the service have their privacy and dignity protected. 30/04/2010 6 12 15 The registered person must give consideration to the comments made by staff and people who use the service, in relation to activities and the frequency with which they are provided. In that this will ensure that people who use the service can benefit from a wide range of personal, recreational and cultural activities programme. 20/06/2010 7 19 23 The registered person must ensure that the ongoing refurbishment plan is effective and renders all areas of the home fit for purpose. Redecoration must be of a high standard. In that this will have ensure that people who use the service, live in a home that is fit for purpose and homely in appearence. 20/07/2010 Care Homes for Older People Page 28 of 32 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 8 22 23 The registered person must 20/07/2010 ensure that fixtures and fittings are updated according to need and that all fittings are in a good state of repair. In that this will ensure that the people who use the service live in an environment that is of sound construction and kept in a good state of repair externally and internally. 9 26 23 The registered person must ensure that the cleaning programme is effective and allows for the home to be maintained in a clean and fresh manner. In that this will ensure that the peole who use the service live in a clean and hmely environment. 20/06/2010 10 26 23 The registered person must ensure that there are appropriate hand washing facilities available for use at all times. In that this will ensure the risk of cross infection is minimised. 30/04/2010 11 33 24 The registered person must ensure that a report is published annually, which 20/06/2010 Care Homes for Older People Page 29 of 32 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 details the findings of Quality Assurance questionnaires. In that this will ensure that issues raised by staff, people who use the service and relatives, are recognised and acted upon. 12 33 26 The registered person must ensure that Regulation 26 Provider Visit Reports are of good quality and are a true reflection of the care, services and environment provided. In that this will ensure that people who use the service will be assured that the Provider is responsive to the changing needs of the home environment and individuals needs are appropriately supported. 13 35 16 The registered person must ensure that all personal allowance accounts held for individuals are accurate, with clear records of transactions being maintained. In that this will ensure that individuals monies are safeguarded. 30/04/2010 20/05/2010 Care Homes for Older People Page 30 of 32 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 14 38 23 The registered person ensure that individuals who smoke, must smoke in the designated smoking area at all times. In that this will ensure that the health and safety of staff and people who use the service are safeguarded. 21/04/2010 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 2 7 7 That daily care entries are written in a manner that is reflective of the care plan. That the Registered Manager completes a Deprivation of Liberty and Mental Capacity assessment of each person who uses the service, within the self imposed two month timescale. That consideration is given to employing a weekend cleaner, in order to keep the home clean a fresh everyday of the week. That the AQAA, training matrix and staff files are cross referenced to ensure that training attended by staff is clearly and consistently recorded. 3 26 4 30 Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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