Care Home: Bilton House

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What the care home does well Pre admission documentation available within the care plans looked at confirmed that the manager of the service was satisfied that the home would be able to meet peoples care and support needs prior to them moving in. Care planning documentation is comprehensive and detailed, and also includes pertinent risk assessments. All of this information is reviewed regularly and updated as necessary to ensure that the staff have the most current information to work from. Relatives are also involved in this process if the resident wishes. Medication policies and procedures in place ensure that this is managed safely on peoples` behalf. Relatives are free to visit the home at any time and are made welcome by friendly and courteous staff. People are offered a variety of activities throughout the week that are planned and coordinated by the homes activites person. In addition informal activities are available and include television, music, jigsaws or reading books, magazines or newspapers. Meals are wholesome, nutritious, tasty, and enjoyed by the residents. Residents and relatives can be sure that any concerns or complaints that they have will be treated sensitively and resolved as far as possible. The homes policies on complaints and protection from abuse safeguard the residents, as does the homes staff recruitment procedures. The environment is comfortable, homely, hygienic, clean and tidy, and is appreciated by both residents and visitors alike. An annual quality survey ensures that residents views are listened to and kept at the forefront of service delivery. Health and safety is managed well. What has improved since the last inspection? Four requirements were made at the last inspection. Three of these centred around medication. The fourth related to staff recruitment. The manager and staff have worked hard to address these requirements as follows: Anyone who chooses to self administer their medication now has a pertinent risk assessment in place to support this. Medication record administration charts are now completed properly with reference to people refusing to take their medication for whatever reason. All staff responsible for administering medication have received appropriate up to date training.Any queries pertaining to staff recruitment such as clarification of information in references received is now recorded. What the care home could do better: No requirements have been generated by this inspection visit. The following good practice recommendations are made: All staff should receive current training in safeguarding vulnerable adults from abuse, to ensure that people are protected from potential harm. Staff should be provided with regular updates in mandatory training to ensure that they are fully able to meet peoples` needs appropiately. Recorded visits in accorance with Regulation 26 of the Care Standards Regulations 2001 should be undertaken on a monthly basis inorder to demonstrate that the provider is monitoring the quality of the service provided by the home. Key inspection report Care homes for older people Name: Address: Bilton House 5 Bawnmore Road Bilton Rugby Warwickshire CV22 7QH     The quality rating for this care home is:   two star good 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: Justine Poulton     Date: 0 9 1 0 2 0 0 9 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 26 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) 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. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: Bilton House 5 Bawnmore Road Bilton Rugby Warwickshire CV22 7QH 01788813147 01788811184 care.biltonhouse@btconnet.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Rugby Free Church Homes For the Aged care home 38 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: 38 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 (OP) 38 Dementia (DE) 38 Date of last inspection Brief description of the care home Bilton House is a residential care home with a Christian ethos and is governed by the Trustees of Bilton House charity. The aim of the charity is to provide a home for the care of older people within the liberal Free Church traditions, and to enable each resident to continue living as independently as possible. Bilton House is a large building, which has been extended over a number of years and Care Homes for Older People Page 4 of 26 Over 65 0 38 38 0 1 0 0 2 2 0 0 9 Brief description of the care home has bedrooms on two floors, which can be accessed by a lift. The property fronts directly onto Bawnmore Road and there is a large visitors car park at the rear of the home, which can be accessed via a side entrance. The home is registered to accept 38 older people 17 of which are for people with a diagnosis of dementia. There is level access to the home for wheelchair users to the front and back of the home. The Clarice Cooper wing accommodates eight residents with a diagnosis of dementia and the main building accommodates the additional nine people with a diagnosis of dementia. Most of these residents occupy bedrooms on the ground floor. At the time of this inspection visit a further extension to provide four additional bedrooms, a new kitchen, dining room and reception area was nearing completion. All rooms in the main building have ensuite showers and toilets. The rooms in the Clarice Cooper wing have ensuite toilets. There are 32 rooms in all but the home have used one of the larger bedrooms as a double hence the registration for 33. There are five communal lounges, large corridor areas, with seating, and one dining area. Information relating to the fees charged for the service provided at this home was not made available to us. The reader may wish to contact the the home directly for this information. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection was carried out to establish the outcomes for people living in this home, and to confirm whether they are protected from harm. Identified key standards were looked at, along with a review of the organisations progress towards meeting any requirements made at the previous inspection of this service. The pre fieldwork inspection record was completed, as well as a site visit to the home, during which time staff, people living in the home, relatives, and the manager were spoken with. A completed annual quality assurance assessment was received from the service prior to the inspection. Care Homes for Older People Page 6 of 26 Three people were identified for close examination by reading their care plans, risk assessments, daily records and other relevant information. This is part of a process known as case tracking where evidence is matched to outcomes for residents. Records, policies and procedures were examined and the environment was looked at. Care Homes for Older People Page 7 of 26 What the care home does well: What has improved since the last inspection? Four requirements were made at the last inspection. Three of these centred around medication. The fourth related to staff recruitment. The manager and staff have worked hard to address these requirements as follows: Anyone who chooses to self administer their medication now has a pertinent risk assessment in place to support this. Medication record administration charts are now completed properly with reference to people refusing to take their medication for whatever reason. All staff responsible for administering medication have received appropriate up to date training. Care Homes for Older People Page 8 of 26 Any queries pertaining to staff recruitment such as clarification of information in references received is now recorded. 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 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 26 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents can be confident that their assessed needs will be met by the home should they decide to move in. Evidence: The care files of three people living in the home were examined to assess the pre admission assessment process. All three included a pre admission assessment carried out by a senior member of staff from the home. This pre admission assessment included information about the proposed reason for admission and principle diagnosis. The pre admission assessments are completed following referral to the homes waiting list which must be accompanied by a letter of reference from the minister/vicar of the prospective residents church. The manager said that when a vacancy becomes available these are then presented to the homes board of trustees in order of priority for consideration. The home does not provide intermediate care. Care Homes for Older People Page 11 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home can be confident that comprehensive, detailed care plans and risk assessments ensure that their well-being and safety is promoted. People can be confident that their medication is managed safely on their behalf. Evidence: All three people chosen for case tracking purposes had care plans, risk assessments and key support records in place. These were all looked at to determine whether and how their assessed needs were being met. They contained satisfactory levels of information which informed staff about what support was needed and how they were expected to provide it for people. The care plans covered areas of care and support which included personal needs and preferences; daily routines; personal care guidance and prompts; personal environment; any equipment used such as a hearing aid, glasses or a walking frame; personal well being worship is very important for X through Bilton House services; personhood which includes such things as things that are important; personal identity; decision making; communication; comfort and inclusion and occupation and significant relationships. Care Homes for Older People Page 12 of 26 Evidence: In addition to the care plans in place each person case tracked also had a number of risk assessments mainly covering their heath needs. Current moving and handling assessments were in place, as well as assessments covering medication management, eating, drinking and nutrition and pressure area and skin viability amongst others. The information contained within the risk assessments in place was detailed and clearly informed staff of the action to be taken to ensure that the risk was minimised. Records of review dates and any amendments made were also in place, and confirmed that they had all been reviewed within the last six months. Medication is managed on behalf of the majority of people living in the home. The few people who are responsible for looking after their own medication have risk assessments in place for this which are reviewed regularly. For example risk assessments for the self medication of eye drops and a GTN spray were seen, both of which had been reviewed in August 2009. Medication is stored within the home in locked trolleys. At the time of this visit these were located temporarily in a lockable walk in cupboard until work on the new treatment room was complete. Medication is supplied to the home by a local pharmacy accompanied by medication administration record (MAR) charts. The storage of medication was deemed to be acceptable on a temporary basis but staff were advised to place a thermometer in the cupboard in order to monitor the temperature as excessive heat may cause a reaction in some prescribed medications. The medications and MAR charts of the people chosen for case tracking purposes were looked at and did not provide any cause for concern at the time of the inspection. The three requirements regarding medication, made at the last inspection of this home had all been addressed. Care Homes for Older People Page 13 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A variety of activities are available for people to choose from if they so wish. Peoples relationships with families and friends are promoted and encouraged and they are made to feel welcome in the home. People can be confident that a healthy, nutritious diet is provided Evidence: The home employs an activities coordinator to plan activities that are appropriate to peoples needs, and that take into account peoples interests and hobbies. These are posted on the homes notice board as a programme of activities on a weekly basis. In addition the home holds weekly services for people to participate in as their faith is very important to them. On the day of the visit various activities were taking place and people were seen to join in if they so chose. One such activity was a bingo session in the main lounge which people said they were enjoying. Another was an art and card making session which was well attended. In addition people were observed to be reading newspapers, going out, having their hair done by a visiting hairdresser and chatting with each other or the staff. People spoken with over lunch said that the home provided a variety of activities that we enjoy, and they were seldom bored. Individual activity records indicate that people enjoy ball games, aerobics sessions, sing-a-longs, trips out, reminiscence sessions and one to one sessions. The annual Care Homes for Older People Page 14 of 26 Evidence: quality assurance assessment (AAA) records that the home could be better at providing activities appropriate for day care and residents with dementia. The manager said that this is something she plans to address over the coming months. Continued contact with families and friends is seen as being of paramount importance for the people living in the home. As such the manager and staff strive to ensure that people are supported with this as they wish. A policy pertaining to contact with family and friends is available, and is provided to families when their relative moves into the home. People are free to receive visitors at any reasonable time, and they can see them in either private or more communal areas as they so choose. A number of visitors were seen to come and go during the inspection visit, and people were also seen to take telephone calls from relatives. Throughout the inspection visit staff were observed to encourage people with making choices and decisions about their lives. This was especially apparent with the people who have dementia as their varying levels of dementia limit their abilities to maintain control and exercise choice over their lives. It was apparent however that the staff work hard at ensuring that people are encouraged to do as much for themselves as they are able. Simple choices such as what to have to eat each meal time, how to spend their time and whether to participate in planned activities are encouraged, as are decisions about when to get up or retire to bed, what to wear and whether to have a bath or a shower. Staff spoken with said that just by encouraging these simple things can make all the difference to people. On the first day of the inspection visit to the home the chef was preparing to move into the newly built kitchen. This move had taken place on the second visit as part of this inspection. The move into the newly built dining room had also taken place. This room was spacious, light and airy, with dining tables and seating that enabled people to sit where they chose, with whom they chose. The dining tables were nicely laid with flowers and appropriate condiments were available. People were individually offered a choice of meals and drinks. The food available was plentiful and nicely presented. People spoken with during lunch time were complimentary of the meals provided by the home, the chef is a good cook, we always have lots to choose from, I look forward to my meals they are the highlight of my day. For those people who either chose not to eat in the dining room or were unable to for whatever reason, staff were available to support them discreetly inline with their assessed needs. Specialist diets such as diabetic, or vegetarian are accommodated. Care Homes for Older People Page 15 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in this home can be confident that the homes policies on complaints and protection from abuse ensure that their views are listened to and acted upon, and that they are safeguarded from harm. Evidence: The home has a complaints policy in place. People spoken with were aware of this and were quite happy that they would know how to use it if they ever felt it necessary. Information in the AQAA states that the home had received two complaints since the last inspection, both of which had been resolved within their own policy timescales. Three complaints were recorded within the homes log, along with details of any investigation that had been undertaken, the outcome of the complaint and any response. We havent received any complaints about this home. As well as recording any complaints received, the home also keeps a record of any compliments or comments that they receive. These included comments such as I thank you from my heart for the kindness to my beautiful Mom, I thank god she is so well looked after, our thanks to you and all the staff for the care and attention you give the residents, and it is lovely to share special time with my Mum in your spacious lounge. As well as a complaints policy the home has a policy on the protection of vulnerable adults from abuse in place. Linked to this are policies for whistle blowing; preventing and responding to aggressive behaviour and physical restraint and intervention by staff. These last two clearly state that any form of restraint or physical intervention are to be used as an absolute last resort and only by staff who have been trained in Care Homes for Older People Page 16 of 26 Evidence: appropriate techniques. Staff spoken with were clear about what constitutes abuse and what they would do if they were to witness, suspect or have an incidence of potential abuse disclosed to them. Staff training records looked at indicated that 15 staff members received training on safeguarding vulnerable adults in March 2008 however there were 17 staff members who had yet to receive any training in this area. This was discussed with the manager who said that there had obviously been an oversight as training had been planned for the remaining staff but had been cancelled for whatever reason. A commitment to ensure that all staff received appropriate training in this area as soon as possible was provided. The management of peoples finances was looked at during this inspection visit. Every person that lives at the home has their own appointee who is either a family member, an advocate or someone appointed via a court. The home does not have any responsibility for managing peoples personal finances. What is in place however, is a bank account that has funds provided by the home for use by the people who live there. For example monies from this account are used to pay for things such as hairdressing, newspapers or clothes occasionally. Also people are free to use this account as a bank sometimes if they run out of personal spending money and require some before they can request it from their own finances. The home then provides each persons appointee with a monthly bill for monies spent which reimburses this fund. This system works well for the people that make use of it. Care Homes for Older People Page 17 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from a homely, clean and well-maintained environment, which they value. Evidence: The main building of the home is very old and grand with high ceilings and many of the original features such as wood panelling and stained glass windows. These contribute to providing a high quality environment in which people quite obviously felt comfortable and at ease. The home was again clean and well-maintained during this inspection visit. There were no unpleasant odours apparent and the domestic staff on duty were observed to be busy throughout both visits, ensuring that the environment remained a very pleasant and homely place for people to live. A number of peoples bedrooms were looked at during this visit, and were very pleasant with personalisation in the form of photographs, ornaments and pictures. Any specialist equipment necessary was stored discreetly and did not impact on the appearance of peoples personal space. The laundry area was impeccably clean and tidy, and the care taken over peoples clothing was apparent in their standard of dress. Care Homes for Older People Page 18 of 26 Evidence: Infection control measures and procedures were in place and were clearly adhered to throughout the home. Since the last inspection a major building project has been taking place in the form of a large extension. People spoken with said that although the building works were extensive, they had not impacted negatively on the rest of the home in anyway, and had not therefore had a detrimental effect on any of the people living in the home. Care Homes for Older People Page 19 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people living in this home benefit from properly recruited sufficient numbers of competent and knowledgeable staff. Evidence: Information contained in the homes completed AQAA says that 33 permanent care workers and nine ancillary staff are employed. Of these 33 care staff, 50 have achieved their NVQ II qualification in care. Duty rosters looked at indicated that the home generally functions with five care staff on duty for the morning and afternoon shifts and three staff overnight. This was deemed to be satisfactory at the present time by staff spoken with, however the manager said that she is currently in the process of recruiting additional staff in readiness for when people move into the four new beds within the new extension. People spoken with during the inspection commented that the staff were lovely and kind, always happy to stop and chat and never too busy to spend a few minutes with me, which i appreciate. Two staff files were checked to determine the robustness of the homes staff recruitment procedures. Both files contained evidence to indicate that Criminal Record Bureau checks are undertaken along with two written references, a full employment history and proof of identity to ensure that any risks to vulnerable adults is minimised. All new staff are provided with a rigorous induction programme upon commencement Care Homes for Older People Page 20 of 26 Evidence: of employment. In addition staff are provided with training in the mandatory areas of food hygiene, first aid, fire safety, moving and handling and medication administration. Staff training records indicated that updates of refreshers in food hygiene and fire safety were required for a number of people. The manager undertook to ensure that these were provided at the earliest possible convenience. In addition staff are provided with non mandatory training in areas such as medication administration, health and safety, safeguarding adults, dementia awareness, equality and diversity, dealing with challenging behaviour, deprivation of liberty safeguards, continence training, bereavement training and diabetes care, thus ensuring that the staff team are equipped and able to provide appropriate care and support to the people resident in the home. Care Homes for Older People Page 21 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in this home benefit from good management systems. Peoples views are sought via an effective quality monitoring system which ensures that their views are at the forefront of service development. People can be confident that that they are safe via effective health and safety management. Evidence: The home is managed by a competent, experienced and suitably qualified manager who is supported by three similarly competent, experienced and appropriately qualified assistant managers. An open door style of management was apparent, and both staff and the people living in the home appeared comfortable and at ease in approaching any member of the management team. The home operates a quality review process that involves seeking the views of residents, relatives and other key stakeholders. Surveys are sent out and information from the returned completed ones is then collated into a report that then generates an Care Homes for Older People Page 22 of 26 Evidence: action plan that informs the continued development of the home. The annual quality assurance survey was undertaken in February of this year. In addition the quality of the service provided is monitored via staff supervisions, and staff meetings. It was noted that the trustees of the board do not carry out recorded monthly monitoring visits as required under Regulation 26 of the Care Homes Regulations 2001. This was discussed with the chairman during feedback about the inspection visit, and the importance of these monthly visits as a tool to demonstrate that they are continually monitoring the quality of the service provided was stressed. Information in the AQAA records that all of the necessary routine health and safety monitoring and checks are in place and up to date. A sample of these which included the landlords gas certificate, fire alarm testing, hot water testing, portable appliance testing and lift servicing confirmed this. A health and safety policy is in place, and staff are provided with health and safety training. Cleaning materials are stored safely and associated control of substances hazardous to health (coshh) data sheets are in place, which ensures that everyone that lives in, works in or visits the home can be confident that they are as safe as practicably possible. Care Homes for Older People Page 23 of 26 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 18 All staff should receive current retraining in safeguarding vulnerable adults from abuse, to ensure that they are protected from potential harm. Staff should be provided with regular updates in mandatory training to ensure that they are fully able to meet peoples needs appropriately Recorded visits in accordance with regulation 26 of the Care Homes Regulations 2001 should be undertaken on a monthly basis in order to demonstrate that the registered provider is monitoring the quality of the service provided by the home. 2 30 3 33 Care Homes for Older People Page 25 of 26 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. Care Homes for Older People Page 26 of 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!