Care Home: Cleeve Lodge

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What the care home does well All prospective users of the service can be confident that their health, social and personal care needs are fully assessed prior to them being offered a place at the home; this is to ensure that both parties are confident that their individual needs can be met appropriately. Staff provide personal care and support to service users in such a way that promotes and protects service users privacy and dignity. The meals provided are freshly cooked on the premises offering variety and choice to meet people`s individual needs and are provided in an unhurried manner, with assistance being given discreetly where required. The home ensures that there are sufficient numbers of staff on duty at all times to meet the needs of the people using the service. What has improved since the last inspection? Since the last inspection improvements have been made in relation to the environment in which people live, adding to their choice and comfort. The changes include major improvements to the central heating system, the purchasing of more comfortable chairs in the lounge, replacing cutlery and crockery for the dining room and replacing fencing to the perimeter of the home to ensure that the grounds provide a safe environment for people living in the home. Monthly resident meetings have been introduced to enable users of the service to express thought and opinions about the service and voice any areas of concern they may have. The service has acted upon the requirements made at the last inspection; cleaning products are now stored securely to ensure the health, safety and welfare of those using the service sought advice from the environmental health officer and have developed and maintained environmental health and safety risk assessments to ensure people`s health and safety.. What the care home could do better: There are a number of issues highlighted within this report which do not meet the national minimum standards/ regulations for which requirements have been made. Review and where necessary ammend the information contained within the statement of purpose and service users guide to ensure people are provided with correct up to date information. Ensure that staff receive regular formal supervision from their line manager and are provided with an annual appraisal of their work to review their performance and plan any future training needs to enable them in their role and in their personal development. The registered manager must ensure a robust recruitment procedure is followed at all times and not employ persons to work at the care home until copies have been obtained of each of the documents listed under Schedule 2 of the care home regulations to ensure that only suitable persons are employed and users of the service are in safe hands at all times. Mandatory staff training needs to be brought up to date to ensure staff have the right skills and knowledge to meet peoples needs and documentary evidence of any relevant qualifications and training must be held in staff personnel files at all times. Key inspection report Care homes for older people Name: Address: Cleeve Lodge 11 Elmhurst Lane Goring On Thames Reading Berkshire RG8 9BN     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: Jane Handscombe     Date: 0 8 0 6 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 28 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 28 Information about the care home Name of care home: Address: Cleeve Lodge 11 Elmhurst Lane Goring On Thames Reading Berkshire RG8 9BN 01491873588 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): evesimmons@btconnect.com Mr Charles Henry Simmons,Mrs Eve Joy Simmons Name of registered manager (if applicable) Ms Penny Camilla Luckett Type of registration: Number of places registered: care home 21 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 to be accommodated is 21. The registered person may provide the following category of service only: Care home only (PC) to service users of the following gender; Either whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (OP) Demenia (DE) Date of last inspection Brief description of the care home Cleeve Lodge is a privately owned care home for people aged 65 and over. It is a large detached Victorian house, modernised and extended, in a quiet road in Goring. There is a lounge, dining room and conservatory on the ground floor, with bedrooms on the Care Homes for Older People Page 4 of 28 Over 65 0 21 21 0 Brief description of the care home ground and first floors. All bedrooms are for single occupancy and five have en-suite facilities. The bedrooms without en-suite facilities are each fitted with a washbasin. The home does not provide nursing care and, when needed, district nurses from the local doctors surgery provide this. Information in regard to the fees is available from the service. Care Homes for Older People Page 5 of 28 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: This was an unannounced inspection, which took place over one day on the 8th June 2010. The purpose of the visit was to see how the service is meeting the National Minimum Standards. Prior to the inspection we required the service to complete an Annual Quality Assurance Assessment (AQAA), which enables them to evaluate the quality of their service and forward to ourselves when asked. This initially helps us to prioritise the order of the inspection and identify any areas that may require more attention during the inspection process. Results of this inspection report are derived from discussions with staff during the inspection, viewing service users records held within the service, viewing policies and procedures, staff personnel files, general observation throughout the visit, information provided to us in the completed AQAA, returned surveys which we sent to the service prior to our visit to distribute to service users and staff members and any other information that we have received about the service in order to gain an understanding of how the service meets the service users needs and how it impacts upon their lives. Care Homes for Older People Page 6 of 28 Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: There are a number of issues highlighted within this report which do not meet the national minimum standards/ regulations for which requirements have been made. Review and where necessary ammend the information contained within the statement of purpose and service users guide to ensure people are provided with correct up to date information. Ensure that staff receive regular formal supervision from their line manager and are provided with an annual appraisal of their work to review their performance and plan any future training needs to enable them in their role and in their personal development. The registered manager must ensure a robust recruitment procedure is followed at all times and not employ persons to work at the care home until copies have been obtained of each of the documents listed under Schedule 2 of the care home regulations to ensure that only suitable persons are employed and users of the service are in safe hands at all times. Care Homes for Older People Page 8 of 28 Mandatory staff training needs to be brought up to date to ensure staff have the right skills and knowledge to meet peoples needs and documentary evidence of any relevant qualifications and training must be held in staff personnel files at all times. 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 28 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 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides clear information about the home and the services they are able to offer which is used by prospective residents to help them choose a home that is right for them. The information is detailed but needs reviewing to ensure people are provided with information which is kept up to date. All residents have their care needs assessed before moving into the home, to ensure that their needs can be met appropriately. The home does not provide for intermediate care Evidence: Information is provided to all prospective and current users of the service, providing them with information about the home and services they are able to offer. The information can be provided in formats to suit peoples individual needs. Whilst viewing the service users guide and the statement of notice, it was noted it contained out of date information, in that the Commissions details had not been updated. The Care Homes for Older People Page 11 of 28 Evidence: registered manager assured us that the information would be updated accordingly to ensure that people had access to up to date information. The manager of the home or her deputy undertakes an assessment of all prospective service users health, social and personal care nees to ensure that the home is able to meet their assessed needs appropriately. The assessment is undertaken in collaboration with the individual and/or their representative. A sample of care plans was examined and very thorough assessments had been made of each of the service users care needs. Wherever possible, prospective residents, family and friends are given the opportunity to visit the home and join fellow residents, in order to gain a feel of the home and meet staff before making a decision as to whether the home is suitable and meets with their expectations. Care Homes for Older People Page 12 of 28 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 home has a clear and consistent care planning system in place that involves service users and their representatives and ensures staff have the information they need to satisfactorily meet the service users individual needs. Poor practices around the recording of administered medication were taking place and need some attention. Evidence: During this visit we chose to view a sample of service users care plans all of which were found to be individualised and personalised detailing their health, social and personal care needs. On each occasion the care plans gave a good reflection of the person, their care needs and how these would be met. The plans were reviewed on a regular basis, and the daily records reflected the care given as set out in the individual care plans. Generally the records viewed evidenced that the service user and/or their representative are involved in the care planning and reviewing process. Risk assessments were found to be contained within those files viewed which included assessments in relation to moving and handling, pressure area care, falls, bathing and Care Homes for Older People Page 13 of 28 Evidence: fire with strategies in place to minimise any such risks. Of the three files viewed one failed to contain an up to date photograph of the individual, which the proprietor assured us would be attended to. The home has good working relationships with healthcare professionals and evidence within service users files informs us that the service accesses them when required and records their visits appropriately within the individuals file. The home has medication policies and procedures in place and staff are provided with appropriate medication training to ensure the health and safety of those using the service. Medication is supplied to the home by a local pharmacy who also support the home in undertaking medication audits and in training staff members. All medication was found to be stored appropriately and securely. We were informed that where medications are to be stored in refrigerators the refrigerators are maintained appropriately with regular recordings of temperature to ensure any medications requiring storage in such conditions are maintained at the appropriate temperatures. However during this visit, no such medications were in use which required such storage conditions. Samples of medication administration records were viewed as part of our case tracking; the medication administration records were not always completed to identify that the said medications had been administered as prescribed by their GPs; an audit of those service users medication who were being casetracked during this inspection acknowledged that their medications had infact been administered. It would be good practice to undertake regular audits to ensure that appropriate records are being maintained. Where people wish to maintain control over the administration of their medication, the service will support people to do so within a risk management process; at the time of this visit there were no service users who had chosen to do so. Residents spoken to overall felt that the care provision was good and that the staff were kind and considerate, respecting their privacy and dignity at all times. Care Homes for Older People Page 14 of 28 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. There is limited opportunity for people using the service to take part in activities suited to their needs and abilities. The home welcomes visitors and encourages people to maintain contact with families. The food provided in the home is of good quality, freshly prepared and cooked on the premises, offering choice and meeting the dietary needs of those using the service. Evidence: Information provided to us in the AQAA completed by the registered person before we visited informed us that the service encourages people living there to socialise and interract and that the activities provided centre around peoples capabilities and preferences. We are informed that entertainers come into the home on a weekly basis to provide entertainment and that the service has good links with religious organisations, day centre, local clubs and societies. We were also informed that the service have made improvements to enable people to access facilities within the local church which include monthly tea dances and weekly coffee mornings. During our visit there did not appear to be any daily activities being provided on the day. Whilst viewing the care plans of those being casetracked, we looked at the documentation informing of what activities they had taken part in; one service users file informed us that since admission to the home in May 2010, only three entries for activities were Care Homes for Older People Page 15 of 28 Evidence: made, two of which were logged as daughter visited and another being listed as phone call. Another service users activity sheet informed us that throughout January, february and up until March 11th the only activity was that of watching television, which had been logged for every day and no further activities logged since. Feedback from users of the service who completed our comment cards were mixed in relation to the provision of activities; we asked if there are activities arranged by the home that they can partake in, four answered always, two answered usually and one said sometimes. Further comments included I would like to go out to the sweet shop to buy sweets when I want to and another said improvements could be made by having the staff available to go out for walks during the day and go into the village. These comments were fed back to the manager during the inspection. It would be good practice to seek the views of those using the service to determin their requirements in relation to daily activities to provide regular, stimulating and engaging activities, suitable to meet peoples abilities, needs and individual preferences. People who use the service are provided with good quality food, which is freshly cooked on the premises and are offered a choice. Special diets are available to meet peoples health and cultural needs and the service endeavours to take individual tastes into account. The dining environment was found to be relaxed and comfortable and residents were able to enjoy their lunch at their own pace with help being provided in a discreet manner where required. Care Homes for Older People Page 16 of 28 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 suitable arrangements in place for responding to complaints by people living there but the service need to satisfy themselves that people know how to make a formal complaint. Appropriate procedures are in place to report and respond to any accidents/incidents or allegations and to safeguard people using the service. Evidence: Information provided to us in the completed annual quality assurance assessment informs us that the service welcomes complaints and suggestions about the service and that each user of the service and their families are provided with a copy of the complaints procedure on admission to the home. However, whilst the home has a complaints procedure in place people using the service inform us that they do not know how to make a formal complaint; all eight service users who completed surveys for us tell us that there is someone they can speak to informally if they are not happy but all apart from one person told us that they do not know how to make a formal complaint. It would be good practice to discuss the procedure with service users both on admission to the home and on a regular basis to ensure they know how to make a complaint and feel comfortable in doing so. The two staff members who completed surveys prior to the inspection both tell us that thay know what to do if someone has any concerns about the home. The service inform us that it is the homes policy to deal with matters as they arise. The service themselves have received one complaint Care Homes for Older People Page 17 of 28 Evidence: during this period, which was resolved within a 28 day timescale. The background to the complaint was discussed with the registered persons during the course of our visit. The Commission has received one anonymous complaint about the service during the last 12 months which was in relation to moving and handling; during this visit we observed moving and handling practices taking place and had no cause for concern. Staff training records highlighted that staff are provided with moving and handling training to ensure that they have the skills and knowledge to handle people appropriately. There are policies and procedures in place to guide the manager and and staff on how to respond to any suspicion of abuse, these are not in line with the Buckinghamshire multi agency policies and procedures and need reviewing. The registered persons assured us that this would be dealt with accordingly. Training is provided to all members of staff to assist them in becoming aware of their own care practices, to recognise signs and symptoms of abuse and to emphasise each staff members responsibility to whistle blow on any poor practice or concerns that come to their attention. No safeguarding referrals have been made during this period of review. Care Homes for Older People Page 18 of 28 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. Service users are provided with a clean, comfortable homely environment with their own belongings around them which is equipped to meet their differing needs. Evidence: The proprietor informed the inspector that the home always encourages residents to bring small items of furniture and memorabilia to personalise their rooms to their own liking, which was confirmed by those spoken to during our visit and evident on touring the home. Service users spoken to on the day informed us that they were happy with their bedrooms and their surroundings, that the home is kept to a high standard of cleanliness at all times. Whilst touring the home it was found that some people were using steradent tablets for the cleaning of their dentures but these were being stored inappropriately and placing people at risk. Risk assessments should be undertaken with regard to the use of and safe storage of steradent tablets and the provider assured us that this would be dealt with appropriately to ensure the health, safety and welfare of those using the service. Accommodation for each resident is furnished and equipped to ensure them the right to comfort and privacy in a homely atmosphere. Whilst touring the home we noted that communal towels were in use in the communal bathrooms; we discussed this issue with the manager and highlighted that this is not Care Homes for Older People Page 19 of 28 Evidence: good practice reccommending that the provision of paper towels would ensure that service users are not subject to the possibility of cross infection. People using the service have access to comfortable and accessible facilities both indoors and outdoors, however the pathway leading around the house was very slippery in one area due to recent weather conditions resulting in a build up of algae, which caused the inspector to slip over. It is reccommended that the pathway is attended to, to ensure it does not present as a falls risk to those using it. Care Homes for Older People Page 20 of 28 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. Generally there are good recruitment processes in place although there is some inconsistency in obtaining and checking necessary documentaion when recruiting staff from agencies. Staff are trained to meet the needs of people using the service although some attention is needed to ensure that refresher training is provided in a timely manner so staff have up-to-date skills to meet peoples individual care needs. Evidence: People using the service indicated on comment cards that staff treat them well and that carers listen and act on what they say. Staff indicated that they are always or usually given up-to-date information about the needs of people to help them provide appropriate support or care and training was described as good. Information provided to the Commission, prior to this visit, informed us that the service has a thorough recruitment process based on equal opportunities and ensures protection and safety of service users. We viewed 3 staff personnel files to include two long standing members of staff and one staff member recruited since the last Key inspection, to ensure that robust recruitment procedures were being followed and to ensure that staff are provided with suitable training to provide them with the skills and knowledge to undertake their roles competently. Care Homes for Older People Page 21 of 28 Evidence: Whilst viewing the staff members files, it was evident that there were serious failings in the recruitment practices taking place within the home, thereby placing those using the service at a potential risk of harm. There was an absence of relevant CRB (Criminal Records Bureau) disclosures, POVA first checks and clearance from Home office enabling a member of staff to work at the home. It is a legal requirement that appropriate checks and clearances are undertaken prior to appointing people to work at the home, to ensure their suitability to work with vulnerable adults. An immediate requirement was made with immediate effect to ensure that no person worked at the care home until all relevant checks and documentation listed under schedule 2 of the care homes regulations were in the homes possession. The registered persons took the appropriate actions to ensure the health, safety and welfare of those using the service. In discussion with the manager we were informed that all newly appointed members of staff undergo induction training upon appointment to their posts, and are provided with mandatory training, offered ongoing training and encouraged to undertake the National Vocational Qualification (NVQ) in Care, which equips them to meet the assessed needs of the residents within the home and allow for personal development. The manager further informed us that of the 11 permanent care staff four have obtained their NVQ qualification at level 2 or above in care with a further five care staff working toward the qualification. Feedback from two staff who completed questionnaires informed us that their induction covered everything they needed to know to do their job when they started and they are being given training that is relevant to their role, helps them to understand and meet the individual needs of those using the service and keeps them up to date with new ways of working. Training records showed some gaps to mandatory courses such as out of date certification for one carer in first aid, food hygiene, manual handling and the lack of certificates for safeguarding vulnerable adults and for managing and safe handling of medication. Another carers file evidenced out of date certification for first aid. Some courses have been booked for staff to attend but others need addressing to ensure staff have up-to-date skills in meeting peoples needs. A requirement is made to address this. The staffing levels on the day of inspection were sufficient to meet the needs of those using the service. Feedback from people who completed questionnaires for us, prior to this visit, informed us that they receive the care and support that they need, that staff are available when they need them and the staff generally listen and act upon what they say. Care Homes for Older People Page 22 of 28 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 and administration of the home aims to promote continuity and good overall personal care for the people who live there. Improvements to staff training and the updating of their skills are needed to ensure that safe practice is in place to reduce the likelihood of injury or harm and staff are to be provided with regular formal supervision from their line manager and have their standard of work appraised on an annual basis. Evidence: The registered manager is experienced, knowledgeable, and is competent to manage the home. She completed the AQAA document when asked to do so and is aware of what needs to be done to improve the home and service that it provides. The home has a health and safety policy statement and provides training for staff on safety topics such as moving and handling residents and fire safety training. We discussed health and safety issues and saw appropriate maintenance records relating to maintaining a safe environment for residents. Regular safety checks are undertaken Care Homes for Older People Page 23 of 28 Evidence: relating to fire safety and infectious diseases and regular servicing and maintenance of equipment, all of which were seen to be documented appropriately The home does not act as agent or manage monies on behalf of those using the service. The home engages regularly with users of the service to gain feedback on various aspects of the service it provides; this is undertaken on both an informal and formal basis through feedback and questionnaires on various aspects of the service and the care provided. It is recommended that the annual questionnaire allows GPs, social workers and any other health professionals involved with the home to take part, to provide for a more rounded view of the service. Whilst viewing a sample of three staff personnel files, it was apparent that staff were not being provided with formal supervision from their line manager on a regular basis. One file informed us that the said carer had not received an appraisal of their work since 2006 and the most recently recorded supervision was dated June 2008. Another carers file evidenced that they had not had an appraisal of their work since 2001 and had received just one formal supervision between July 2008 and March 2010. We discussed these findings with the manager who assured us that staff are provided with supervision on an informal basis regularly and further assured us that she will ensure to record formal supervisions appropriately. Staff spoken to felt that their manager gives them support and is readily available if they wish to meet with her to discuss any concerns they may have. A requirement has been made within this report to ensure that care staff receive formal supervision regularly to review their performance and plan any future training needs to enable them in their role and in their personal development. Care Homes for Older People Page 24 of 28 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 28 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 1 4 Review and where necessary 06/08/2010 ammend the information contained within the statement of purpose and service users guide. This will ensure ensure that people have access to up to date information. 2 30 18 Mandatory staff training is to 30/09/2010 be brought up to date. To ensure staff have the right skills and knowledge to meet peoples needs. 3 36 18 Ensure that staff receive regular formal supervision, are provided with an annual appraisal of their work and appropriate documentation to evidence these are held within staff personnel files To review their performance and plan any future training 30/09/2010 Care Homes for Older People Page 26 of 28 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 needs to enable them in their role and in their personal development. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations Care Homes for Older People Page 27 of 28 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. © 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. Care Homes for Older People Page 28 of 28 - 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!