Care Home: Ellacombe

Similar services:

• Claremont House
• Oak Ridge
• Sun Court Nursing Home
• Ashville House
• Bilney Hall
• Hill Barn
• Mabbs Hall Nursing Home
• Henrietta House

What the care home does well There was a thorough admission process. People thinking of moving into the home were given information and were encouraged to visit so that they had a good idea of what they could expect at Ellacombe. The manager carried out an assessment with new people to make sure that staff understood and could meet their needs. Residents told us that staff looked after their health very well and the records showed that they were referred to health care professionals whenever it was necessary. One person said, "I was in a real state when I came in here and they looked after me really well." Residents who sent in surveys indicated that they received the care and medical support they needed. Staff made sure that residents received their medicines as they were prescribed by the doctor. Staff made sure that the principles of privacy and dignity were put into practice when they provided care. A resident told us that staff were always respectful. Staff told us there were no strict routines and residents had 100% choice. Residents we spoke to were happy with their daily lives in the home. One said the home was, "like a first class hotel." There was a programme of activities on offer, which included some trips out, either in small groups or one to one with staff. We were told, "There is plenty to do if you want it." Residents were offered a varied diet with choices at every mealtime. Those who completed surveys indicated that they usually liked the meals and those we spoke to said they were satisfied with the food. Residents told us that they did not have any complaints but they knew who to speak to if they did. The records showed that all complaints were taken seriously and responded to. Staff had training and written guidance in adult protection. They understood their responsibility to report any suspected incidents to the manager. New staff all had background checks before they started working at the home. This was to make sure that they were suitable to work residents. Staff had training to help them to understand the needs of the people who use the service and to protect their health and safety. Over half of the care staff held an NVQ, which is a nationally recognised qualification in health and social care. What has improved since the last inspection? We did not make any requirements or recommendations for improvements following the last inspection. However, in the annual quality assurance assessment (AQAA) the manager told us about improvements that had been made, in all areas, over the past year. Some of these have been mentioned in the body of the report. What the care home could do better: We found some gaps in the care plans. Residents must have care plans to tell staff how to meet all of their health and personal care needs. Bathrooms should not be used for storing moving and handling equipment. The manager should also give some thought as to whether an alternative storage area could be found for unsightly clinical waste bins.The staffing levels should be kept under review to ensure that there are always enough staff on duty. This is to make sure that residents do not have to wait an unreasonable length of time for staff attention. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Ellacombe Ella Road Norwich Norfolk NR1 4BP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Jane Craig     Date: 0 1 0 7 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 27 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: Ellacombe Ella Road Norwich Norfolk NR1 4BP 01603613173 01603624005 ellacombe@norfolk.gov.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Norfolk County CouncilCommunity Care care home 42 Number of places (if applicable): Under 65 Over 65 42 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home 0 Ellacombe is a purpose built residential care home providing care for up to 42 older people. The home is situated within walking distance of the city centre with many shops and facilities. The home has a small car park and on street parking is available for a limited period. Ellacombe is also close to the railway station and main bus routes. At the rear of the home there are two garden areas which are landscaped and provide a pleasant area to sit during the summer period. The current fee level for the home is 384 pounds per week. There are extra charges for newspapers, hairdressing and toiletries. Information about the home, including the latest inspection report, is available from the manager. Care Homes for Older People Page 4 of 27 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 last key inspection on this service was completed on 6th July 2007. This key (main) inspection includes information gathered since the last inspection and an unannounced visit to the home. The visit was carried out on 1st July 2009 by one regulatory inspector. At the time of the visit there were thirty seven people resident in the home. We met with some of them and asked about their views of Ellacombe. We spent time observing daily routines in the home and how staff interacted with residents. Three residents were case tracked. This meant that we looked at their care plans and other records and talked to staff about their care needs. Care Homes for Older People Page 5 of 27 We talked to the registered manager and other members of the staff team. We looked around the home and viewed a number of documents and records. As part of the key inspection surveys were sent out to people living and working at Ellacombe. Their responses have been taken into account when making judgements about the service. This report also includes information from the annual quality assurance assessment (AQAA), which is a self-assessment report that the manager has to fill in and send to the Commission every year. What the care home does well: What has improved since the last inspection? What they could do better: We found some gaps in the care plans. Residents must have care plans to tell staff how to meet all of their health and personal care needs. Bathrooms should not be used for storing moving and handling equipment. The manager should also give some thought as to whether an alternative storage area could be found for unsightly clinical waste bins. Care Homes for Older People Page 7 of 27 The staffing levels should be kept under review to ensure that there are always enough staff on duty. This is to make sure that residents do not have to wait an unreasonable length of time for staff attention. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.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 8 of 27 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 27 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. Staff received sufficient information about new residents to enable them to understand their needs. Evidence: Information about Ellacombe was sent out to people who were referred to the home by their social worker. The annual quality assurance assessment (AQAA) told us that the information had recently been reviewed to make it more meaningful. All the residents who returned surveys indicated that they received enough information to help them to make a decision about whether the home was suitable for them. A member of staff told us that people thinking of moving into Ellacombe were also invited for a trial visit so that they could, sense the atmosphere. The AQAA indicated that, as part of the admission process, the manager always obtained a copy of the social workers assessment. He also carried out his own Care Homes for Older People Page 10 of 27 Evidence: assessment with anyone referred to the service. This helped to ensure that the service was suitable to meet the persons needs. The example of the pre-admission assessment that we saw was quite brief but there was sufficient information within other documents to ensure that staff could draw up an initial care plan. Care Homes for Older People Page 11 of 27 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. Residents received care that met their assessed needs. Evidence: We looked at the care files of three residents as part of the case tracking process and others were looked at to check specific issues. Everyone had a care file, which contained a set of assessments and care plans. However, not all care needs identified in residents assessments had relevant care plans. For example, documents on one residents file indicated that they emotional care needs but there was no plan to tell staff what support they should give. Residents had a care plan summary, which was kept in their bedroom and used by staff on a day to day basis. One of the examples we saw was very detailed. It took into account the residents abilities and told staff how to help the resident to maintain their independence. Another summary we looked at was not as person-centred. Although it instructed staff that total care was needed, it did not mention any of the residents Care Homes for Older People Page 12 of 27 Evidence: personal preferences or wishes. Residents, or their representatives, could be involved in care planning and reviews if they wished to. One resident told us they had a sheaf of paperwork in their room that they sometimes looked at. A number of care plans indicated whether the resident had capacity to agree to their care. There were a list of dates to show that care plans and associated records were reviewed. There were no evaluation notes to summarise the care given or show the residents progress towards meeting their goals. Most of the plans we saw had been updated when the residents needs changed and staff who completed surveys indicated that they were always kept up to date with the residents needs. Residents had health care risk assessments on their files. Those with moving and handling needs had appropriate plans in place. All had nutritional risk assessments. The two residents who always had bedrails had very thorough risk assessments in place. Although it was not part of the care plan, some staff used a bedrail for a third resident. We discussed with the manager that this must be assessed to ensure the residents safety. The care records we looked at showed that residents were referred to health care professionals for advice and treatment. Residents who completed surveys indicated that they always, or usually, received the care and medical support they needed. Everyone we spoke to said that staff looked after their health. One resident said, I was in a real state when I came in here and they looked after me really well. Another told us, I dont have to ask to see a doctor if I am not well, staff do it for me. A member of staff commented, The residents welfare is the most important thing and all staff are aware of that. The service had a dignity champion who was working with a team of staff to raise awareness of dignity in care. She told us that residents were always treated with dignity but the team have helped to make sure that the principles of dignity, and residents rights, run through all aspects of care. Throughout the course of the visit we heard staff talking to residents in a polite and friendly way. One resident told us, they are all respectful but we can have a bit of a laugh. Staff with responsibility for handling medicines were trained and had clear policies and procedures to refer to. Medicines were stored safely and at the recommended temperatures. Residents had lockable cabinets in their bedrooms to store creams. Care staff signed when they administered the creams and other topical medicines. Care Homes for Older People Page 13 of 27 Evidence: The manager told us that the service was trying out a system to make the administration of medicines more person centred. When fully implemented it would mean that instead of having a medicine round residents would have their medication at the time it suited them. For example, night time medicines could be given when the resident was ready to go to bed, rather than them having to wait up until the medicines were given out. There were complete records of medicines received, disposed of, and of any stocks of medicines carried over from the previous month. These records contributed to the audit trail and helped to minimise any risk of mishandling. There were no gaps on medication administration record (MAR) charts, which indicated that residents received their medication as it was prescribed. Appropriate codes were used to show when medicines were omitted. We checked a small sample of medicines and found that the amount of stock accurately matched the records. There were records of unused medicines returned to pharmacy. We discussed with the manager how the storage of medicines waiting to be returned to pharmacy could be made safer to reduce any risks to residents and reduce the risk of mishandling. All residents receiving medicines or creams that were prescribed, when required, had risk assessments in place. Staff also recorded the reason each time they administered pain relief, which we thought was good practice. Variable doses were recorded, which helped staff to evaluate the effects of the medicines. There were some handwritten entries on MAR charts. Although these matched the instructions on the medicine labels, they were not checked to reduce the risk of transcribing errors. Controlled drugs were stored, recorded and administered in accordance with the policy. Since the last key inspection we received four notifications of medication errors. Some of these had been identified during the monthly medication audits that were carried out in the home. The notifications showed us that the manager or senior staff dealt with the errors appropriately. They ensured the safety of the resident concerned and put systems into place to reduce the risks the errors happening again. Care Homes for Older People Page 14 of 27 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 level of choice, the activities and the meals matched the expectations of the residents. Evidence: The care records we looked at included information about the residents past social and family history, which was used to help staff to get to know residents. Two of the residents we case tracked had a social care plan. However, there was very little information about their current interests and how they preferred to spend their time. There was a part-time dedicated activity organiser and named staff were nominated to arrange activities on other days. The AQAA told us that the manager was hoping to improve the level of activities on offer, particularly one to one time and trips out. However, the residents who completed surveys and those we spoke to said their were enough activities to satisfy them. One person said, We do all sorts of things, and another said, There is plenty to do if you want it. It was evident from talking to staff and residents, that the routines in the home were very flexible and were led by the residents. A temporary member of staff told us, Care Homes for Older People Page 15 of 27 Evidence: There are no strict routines, it is 100 residents choice, which is what I love about it. Another staff said, We do everything to accommodate the residents. Residents we spoke to said they were satisfied with the level of choice they had about their daily lives. One told us, I like to get up at 7 oclock so I just call them and they come and help me. There was open visiting, which helped residents to maintain contact with their relatives and friends. Residents also had a choice if they did not wish to see particular visitors and this was recorded on their care plan. Several of the residents we spoke to said they had enjoyed recent trips out to local places of interest. The activity programme also built in one to one trips out, for example, into town. Some residents went out on their own and others with family and friends. Residents did not have any involvement in menu planning, which was done centrally for the county council residential services. However, minutes of the residents meeting showed that they were able to make suggestions for slight alterations and these were acted upon by the cook. The residents who completed surveys and those we spoke to said that they usually enjoyed the meals. One said, The food is gorgeous, and another told us, On the whole the meals are very nice, nothing to complain about. At lunchtime we observed that the dining room was attractively laid out and staff were offering assistance to people in a sensitive manner. A number of residents we spoke to told us they liked the home and were happy living there. One person said, I am very happy here, this is my home. Others commented that Ellacombe was, beautiful, and couldnt find better than this. A resident who had recently come into the home said they definitely wanted to stay. During the course of the visit we observed a friendly relaxed atmosphere in all areas of the home. When they had time to, staff spent time with residents, chatting and laughing. More than one resident told us they enjoyed having a laugh with the staff. Care Homes for Older People Page 16 of 27 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. Complaints were dealt with appropriately and procedures and training were in place to help to ensure that people were safeguarded from abuse. Evidence: The Norfolk County Council complaints procedure was available to residents and visitors. The service users guide also provided contact details for the Commission, should people wish to make a complaint outside the home. The manager had also introduced a system for people who wished to raise issues without making a formal complaint, for example about meals. This had improved the recording of minor grumbles and ensured that they were responded to. All but one resident who returned a survey indicated they knew how to make a formal complaint. The residents we spoke with during the visit said they did not have any complaints but could go to the manager if they did. Staff said they knew how to respond to complaints and the manager told us he was planning some further training in this issue. The AQAA told us there had been seven complaints in the last year. The records showed that they were all investigated thoroughly and responded to within the timescales outlined in the procedure. Care Homes for Older People Page 17 of 27 Evidence: Staff received training in safeguarding adults during their induction and NVQ training. A member of staff we spoke to said they were confident they would be able to recognise any signs that a resident may be a victim of abuse and said they would report it. One said, My conscience would not allow me not to. The Norfolk County Council adult protection procedure was available for reference. There was also an updated procedure to guide staff on how to respond to an adult protection concern. There were leaflets for residents and visitors, which explained about adult protection issues. Residents who returned surveys all said they knew who to speak to if they were unhappy about anything. Senior staff had received training about the Mental Capacity Act and Deprivation of Liberty Safeguards. There was information on display to explain to residents, staff and visitors how the legislation could affect people using services. All the residents we case tracked had an initial mental capacity assessment to indicate whether they were able to make decisions about day to day or significant events. One resident told us they carried a special card about their wishes with regard to treatment, and staff had put a copy on their file. Care Homes for Older People Page 18 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The overall standard of decoration and cleanliness gave a homely, comfortable feel to the home and provided a pleasant place to live. Evidence: The home was split into six smaller units, each with its own lounge. There was also a large communal lounge on the upper floor, which gave residents a choice of seating areas. From a tour of the building we saw that all areas were well maintained. Decor and furnishings were homely and comfortable. Some areas had recently been upgraded, for example the kitchen, and the manager was clear about the plan for further redecoration and renewal. There were two attractive garden areas with a range of seating. A resident told us that the gardening group had helped to plant and maintain some of the flowers. Another said, we are very lucky to have these in the middle of the city. Some of the bedrooms were en-suite and there were ample toilets situated throughout the home. There was a range of assisted bathing facilities on the units and one of the care plans we looked at specified which bathroom the resident preferred. Attempts had been made to make the bathrooms look homely and pleasant for residents having a relaxing bath. However, the storage of large clinical waste bins in the bathroom Care Homes for Older People Page 19 of 27 Evidence: detracted from the homeliness. There were also a number of hoists and other moving equipment stored in bathrooms. The manager had highlighted the lack of storage space in the AQAA and had not been able to find an alternative that did not compromise residents safety. Other equipment, such as grab rails, was in place to assist people with their mobility. Four of the bedrooms had overhead tracking for use with the hoist. Many of the bedrooms were personalised with ornaments and pictures. All the residents we spoke to were satisfied with their bedrooms. One told us, I have everything I need in here. On the day of the visit the home was clean and free from unpleasant odours. Residents who completed surveys indicated it was always like that. One resident told us, It is a marvellous place, always nice and clean. The laundry was adequately equipped for the size of the home and there were laundry staff on duty seven days a week. On the day of the visit the laundry was well organised and there were no complaints about laundry from any of the residents. One told us, I put my dirty clothes out and they take them in the morning and they are back in the afternoon. Staff had written guidance on infection control procedures, including the universal precautions. Staff had training during their induction and there was refresher training planned. There were ample supplies of protective clothing around the home, which staff told us they used. Care Homes for Older People Page 20 of 27 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. Recruitment procedures provided safeguards for residents and the level of staff training meant that staff had the knowledge and skills to meet peoples needs. Evidence: A number of the residents we spoke to said that they did not think there were enough staff. One person who returned a survey wrote that the service could do better by having more staff. Some residents told us that they had to wait for staff to help them. One said staff were around to help them to get up but then they had to wait a long time to get dressed. Residents also told us that there were problems during staff break times. One said, We need someone to take the place of people on breaks but ones who know what to do, not just to watch over us. There had also been a recent increase in the use of agency staff and one resident told us, Staff are changing all the time, I dont know what is going on. The manager was already aware and was trying to address these issues, through recruitment and changing the way staff work. For example, the manager discussed how staff would be allocated to a particular unit for the duration of their shift, which should help with staff presence and with continuity of care. The manager planned to discuss this at the residents meeting. Residents were all complementary about the staff team. One told us, We all get on fine. Another said, The staff are very good, they carry out their jobs with great Care Homes for Older People Page 21 of 27 Evidence: determination. Other comments included, They are all marvellous, nice girls, and very caring. New staff were employed in accordance with the robust procedures of the county council. The manager told us that staff did not start work at the home until they had received satisfactory pre-employment checks, which helped to provide safeguards for residents. New staff completed a thorough induction training programme, which covered the standards of the national training organisation. The programme was delivered through a mix of taught sessions, self study and shadowing, which helped to make sure that staff had opportunities to discuss the training and clarify any issues. Staff who completed surveys indicated that the induction training provided them with the knowledge they needed to do their job. Staff who completed surveys, and those we spoke to, said they received training to keep them up to date and to help them understand the needs of the residents. The central training record was not completely up to date but showed that most staff had received mandatory training in health and safety topics such as moving and handling. Over half of the care staff also held an NVQ at level 2 or above. Care Homes for Older People Page 22 of 27 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. Residents and staff benefited from a safe and well managed home. There was a good level of consultation which meant that residents were able to contribute to service development. Evidence: There was an established management structure within the home. The registered manager had several years experience of managing services and he had recently completed the registered managers award. From information received in the AQAA and observations during the site visit, it was evident that the home had good management and administration systems in place. There were systems in place for monitoring the quality of the service. For example, the annual survey had been completed in November 2008. The manager distributed a summary of the results with the newsletter, which was sent out to people with an interest in the service. There were regular residents meetings. The manager told us Care Homes for Older People Page 23 of 27 Evidence: these were usually within the individual units because residents felt more comfortable contributing in smaller groups. Records showed that any suggestions for improvements during these meetings were acted upon. In addition to staff meetings, staff had regular supervision with their line manager and an annual appraisal to ensure that they continued to provide a high standard of care. Survey results and issues raised during residents and staff meetings helped to inform the annual development plan for the service. The AQAA told us that there were a number of Norfolk county council policies that had not been reviewed for some time and it was not clear whether they still reflected current best practice. Residents who were not able to manage their own finances had families or other representatives to assist them. A number of residents had small amounts of money held at the home for safekeeping. There were secure facilities and clear records were kept of any financial transactions. We audited a small sample and found them to be correct. The records were checked every month to ensure that any errors were identified. All staff had received fire safety training. Fire alarms were tested regularly and other fire safety equipment had been serviced. The AQQA showed that the maintenance and servicing of other equipment and installations were up to date. This helped to protect the health and safety of people living and working in the home. Care Homes for Older People Page 24 of 27 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 27 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 7 15 Care plans must be in place to address assessed needs. This is so that staff know what care they should be providing to meet the residents needs. 31/08/2009 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 3 9 19 37 Handwritten entries on MAR charts should be double signed to evidence that they have been checked. Alternative storage should be sought for moving and handling equipment and large clinical waste bins. Policies and procedures should be reviewed to ensure they provide up to date guidance to staff. Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 27 of 27 - 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!