Care Home: Glenavon House

What the care home does well The admission process is well-managed and new people and their families are given clear information regarding the service and therefore know what they can expect if they move to live in Glenavon Nursing Home. People who live here will be well looked after. The care planning processes and medication procedures mean that people can be assured their personal and healthcare needs will be appropriately met. People will have the opportunity to participate in a variety of different activities, pursue their own interests and choose how they spend their time. They will be provided with a well balanced and nutritious diet. The people who live here can be assured that any complaints they may have will be listened to and acted upon, and that they will be cared for by staff who will safeguard and protect them. Glenavon Nursing Home provides a comfortable and homely environment that is well maintained and equipped to meet the needs of the people who live there. The people who live in Glenavon will be cared for by staff who are skilled and competent to do their jobs, so they can be assured that their needs will be met. The people who live in this home will find that it is well managed and run in their best interests. It is safe and their welfare will be protected. What has improved since the last inspection? There were two requirements made after the last key inspection in June 2007 and these have both been complied with. People have the opportunity to participate in a different activities and those people that were spoken with were satisfied with the things that are arranged. We also saw that records are now made when the registered provider visits the home to complete an audit. What the care home could do better: One requirement has been issued in respect of staff training. Protection of Vulnerable Adult or Safeguarding refresher training must be arranged for the staff team so that they have greater awareness of all issues relating to this subject. This is so that they will always safeguard the people who are living in the home. One recommendation has been made about record keeping in respect of medication administration record (MAR) charts. Hand written entries on MAR charts should be countersigned to make sure they are correct. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Glenavon House 22 St John`s Road Clifton Bristol BS8 2EZ     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: Vanessa Carter     Date: 0 3 0 6 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: Glenavon House 22 St John`s Road Clifton Bristol BS8 2EZ 01179734232 01179064087 glenavonhouse@tiscali.co.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) : GemleighLimited care home 29 Number of places (if applicable): Under 65 Over 65 29 old age, not falling within any other category Additional conditions: 0 Manager must be RN1 or RNA on the NMC Register May accommodate up to 29 Persons aged 65 years and over receiving nursing care Of these 29 persons, 5 may be aged between 50 - 65 years with Physical Disabilities Staffing notice dated 03/11/1998 applies. Date of last inspection Brief description of the care home Glenavon is registered as a care home to give people who use the service, nursing and personal care. Glenavon can accommodate up to 29 people of which five can be between the ages of 50 to 65 years. The home is privately owned by Mr and Mrs Cater and is registered as a company called Gemleigh Ltd. The home is situated in the Clifton area of Bristol and is close to local shops and amenities. It is a detached period property, and accommodation is provided over three floors with lift access to all rooms. The gardens to the rear are secluded and well tended. People in wheelchairs can access the garden by going round the side of the house. 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 inspection of this service was undertaken in June 2007 and our overall judgement about the quality of the service provided for the people who live in Glenavon Nursing Home was that people received a good quality service. After that inspection we planned to visit the service again within two years. In the meantime, we completed an annual service review on 19 June 2008 and were assured that the service was still providing good quality outcomes. Prior to this inspection the registered manager completed the annual quality assurance assessment (AQAA). This is a self assessment document that focusses on how well outcomes are being met. The assessment had been completed in detail and told us about the improvements that have been made over the last 12 months and identified Care Homes for Older People Page 5 of 27 those areas where they still feel they could do better. During the inspection we looked at records kept by the home, including care records, staff records and those that are kept in respect of the running of the home. We spoke to those staff on duty, the registered home manager, and we observed the interactions between the staff and the people who live in the home. We also spoke to six people who live in the home and asked them what it was like to live there. At the time of this report, the fees for placement in the home range between 516 and 700 pounds per week. Additional charges may be made for other services and these are detailed in the homes brochure. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. Care Homes for Older People Page 7 of 27 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. The admission process is well-managed and new people and their families are given clear information regarding the service and therefore know what they can expect if they move to live in Glenavon Nursing Home. Evidence: The statement of Purpose has not been changed since the last inspection and still reflects the service and facilities available. There is also a service users guide and this is given out to people who enquire about the home. Both documents meet the guidance set out in the national minimum standards and contains all the necessary information to enable people to make a choice about living at Glenavon. One person who had recently moved in to the home said that their relatives had received information about the home that helped them make up their minds that the home was the right place for them. Care Homes for Older People Page 10 of 27 Evidence: No person is admitted to the home without having first being visited by the Home Manager. This may take place in the hospital ward or the persons own home. The purpose of this visit is to complete an assessment of the persons needs to make sure that the home is able to provide the level of care that they need and has the right faciltities. The home uses a comprehensive assessment tool to record the specific needs of the person, and this will form the basis of ongoing care planning. It covers social information, communication needs, mobilisation, eating and drinking, personal hygiene,and medical and nursing needs. The assessment of the most recently admitted person was viewed and had been completed prior to the date of the persons admission. The person told us that they had been visited on the hospital ward by the home manager who had asked me a lot of questions. In addition, the home will expect to be provided with social services assessments and care plans and health needs assessments where the placement is being funded by the local authority. Relatives would always be encouraged to view the home, and if possible, the person themselves. The home provides placement for up to 29 older people with nursing care needs. Of the 29 beds available it is able to accommodate up to five people who are aged between 50 and 65 years of age, and who have physical disabilities. The home has in the past looked after people who are younger than 50 years old and have notified us of such. The homes does not accommodate people with a dementia illness although will continue to look after those people who are already placed at the home, who develop the disease, for as long as they are able to meet their care needs. 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. People who live here will be well looked after. The care planning processes and medication procedures mean that people can be assured their personal and healthcare needs will be appropriately met. Evidence: A plan of care is prepared for each person upon admission to the home and this sets out the specific care needs of the person. Core care plans are individualised with additional information for each person. The care planning documentation for three people were examined, including that of the most recently admitted person. The plans each contained a full assessment of the persons individual needs and instructions for the staff in how these identified needs were to be met. The home manager generally completes all the care plans. The plans were supported with risk assessments around manual handling procedures, the likelihood of developing pressure sores and nutrition needs. The plans were person centred and evidence that each person is seen as an individual. The care plans are Care Homes for Older People Page 12 of 27 Evidence: reviewed on a monthly basis and are amended as required. A daily record is kept for each person and it was possible to evidence that peoples care and support needs were being met. The records were respectful of the person and good accounts were made of any significant events. A record is kept when other healthcare professionals have visited or been consulted for advice about the ongoing care of the person. we saw that where necessary people will be registered with the local GP soon after admission - if the person previously lived in the Clifton area, they are able to stay registered with their family GP. We saw that appropriate pressure sore prevention equipment is being used where this is needed. Records of GP contact will include the reason for the visit and the outcome. One person was being supported to attend an out-patients appointment on the day of the inspection. The home has well managed systems in place for the ordering, receipt, storage and disposal of medications. We were told that medications are now supplied in a monitored dosage system, that there are now three trollies, one for each floor. The manager and registered nurse explained that this was much easier to manage. Where oxygen cylinders are stored and in use, we saw that official signage was in place. In order to prevent any mistakes happening, it would be good practice for a second person to check and to sign when hand written enteries are made on medication administration records. People spoken with during the inspection confirmed that they were well looked after and that they get the support that they need. Observations of the interaction between staff and the people in residence evidenced that they are well thought of and treated with respect. The home will continue to look after people when they are in the terminal stages of their illness and are dying. The manager spoke about recent cases and how they had managed to support people to die in their home rather than be admitted to hospital. The manager and other staff will attend funeral to pay their final respects. The home has good links with the local hospice and the manager and other registered nurse have attended syringe driver training, in order to be able to administer adequate pain relief medications. Care Homes for Older People Page 13 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. People will have the opportunity to participate in a variety of different activities, pursue their own interests and choose how they spend their time. They will be provided with a well balanced and nutritious diet. Evidence: The people who live in this home are able to participate in a range of different activities that are arranged by the home, or they can pursue activities independently of the home. One person has recently started to attend a church day centre whilst others go out on a regular basis with support workers. One person is supported to go out every day for lunch and others are taken out to the local shops on a regular basis. Other people said that they preferred to spend their time in their rooms and did not want to mix with the other people. During a look around the home we observed people reading newspapers, listening to the radio, watching TV and sitting in the sunshine and chatting with others. One member of staff arranges activities and we were told there was a clothes show the day before, a group of Chinese singers had recently visited the home and bingo, arts and crafts sessions and music is laid on. Several of the people were making use of the Easter bonnets they made earlier in the year. Care Homes for Older People Page 14 of 27 Evidence: The home has an open visiting policy and people may receive visitors at any reasonable time. We were told that one persons relative regularly brings in their pet dog and that pat a pet have visiting the home with great benefits for the people who live there. We spoke with people after the midday meal had been served on the day of inspection, and were told that the meal was good. We received comments that the food is generally very good - home cooking, I am given far too much to eat and I have to leave some. I hate doing that and We had chicken and mushroom pie today and it was delicious. The cook is currently undertaking a National Vocational Qualification in Catering at Level 2 and has already completed Food Hygiene training. The home has a four-week menu plan. The manager ensures that feedback is always gained from the people who live in the home in respect of the menus and asks them to make suggestions for meal choices. The menu choices for the day are displayed on the chalkboard in the main hallway. People can be served their meals in the main dining room or one of the lounges, or in their own bedrooms, they are able to choose. Care Homes for Older People Page 15 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. The people who live here can be assured that any complaints they may have will be listened to and acted upon, and that they will be cared for by staff who will safeguard and protect them. Evidence: The homes complaints procedure is included in the Statement of Purpose and is displayed in the entrance to the home. Those people spoken with during the course of the inspection said they knew how to raise concerns and would ask to speak to the manager or one of the trained nurses. In the last 12 months the manager has dealt with a number of complaints and from the records kept we were able to see the measures that were taken in dealing with the issues raised and the actions taken to bring about a resolution. The Commission have not received any complaints or concerns about this service. The home has demonstrated in the past that they act in the best interests of the people who live there and have taken the appropriate measures to safeguard people from any harm. The manager and some of the registered nurses have attended Mental Capacity Act (MCA) training and Deprivation of Liberty Safeguards (DOLS) training. The manager has also made a DOLS referral to the local authority in respect of one person and an advocate was used to act on behalf of the person. The home has followed agreed protocol (protection of vulnerable adult (POVA) procedures) and Care Homes for Older People Page 16 of 27 Evidence: informed the local authority and/or the police, where there were concerns regarding the welfare of an invidual. The manager is fully aware of safeguarding procedures and knows what to do and when to share information with other agencies. Staff spoken with during the course of the inspection were aware of abuse issues and for reporting bad practice however were not so aware that their actions or non-actions could be seen as abuse. The manager has had a recent staff meeting where staff attitudes, standards of care delivery and shortcuts in working practice were discussed at great length. We discussed with the manager the need for refresher training in adult abuse awareness for the care staff - this should be actioned as a matter or urgency. Despite this shortfall, there are no concerns regarding the safety of the people who live in the home, as the manager is fully aware of what is happening. Care Homes for Older People Page 17 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. Glenavon Nursing Home provides a comfortable and homely environment that is well maintained and equipped to meet the needs of the people who live there. Evidence: Glenavon Nursing Home is an elegant Victorian property, located in the heart of Clifton, Bristol, close to both shops and local amenities. It is a detached property, and although there are a number of steep steps up to the main front door, there are ramped accesses to both sides of the home. An internal lift ensures that the home is fully accessible to people with reduced, or no independent mobility. Radiators with low temperature surfaces are installed throughout the house for safety. All fire doors are fitted with magnetic devices that will release the doors in the event of the fire alarm system being activated. The living accommodation is arranged over three floors. In addition, the basement area accommodates the laundry, kitchens and staff rooms, but this part of the home is for staff use only. Communal space consists of a lounge area, dining room and a large conservatory. The dining room has recently been redecorated and carpets have been replaced throughout. The whole home is well decorated and was clean and tidy and fresh smelling. There is a paved courtyard to the rear of the house with established flower beds and outdoor furniture. Several of the people spent their time sitting out in Care Homes for Older People Page 18 of 27 Evidence: the garden enjoying the warm weather. To the front of the home there is a limited amount of car parking space. We were told that new chairs are being purchased for the lounge room and new garden furniture for the courtyard. There are toilets and bathrooms located throughout the home in sufficient numbers to meet the needs of the people who live there. Since the last inspection, one of the bathrooms has been converted into a level access shower room, and this is a much better facility to meet peoples needs. One person spoken with during the inspection said It used to be such an effort having a bath, having a shower is so much easier for me and the staff. The home has sufficient moving and handling equipment to meet the needs of the people who live there. This will ensure that staff are able to move people safely. The home has four hoists, one stand-aid, and range of different types of slings and sliding sheets. The home has three specialist nursing beds (profiling beds) and two hospital type beds plus a supply of pressure relieving aids. The home is able to accommodate up to 29 persons, however some of the shared rooms are being used by just one person, thereby reducing occupancy to 25. There are 22 bedrooms - three shared rooms and 19 single. Only one of the bedrooms has an ensuite bathroom, whereas the others have vanity units fitted and can be supplied with commodes where needed. Most of the bedroom were seen during a tour of the home. They were each appropriately furnished, and reflected the persons individual personality. Some of the rooms have been freshly decorated and we were told that when rooms are vacant, they will be refreshed ready for the next person to move in to. Care Homes for Older People Page 19 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. The people who live in Glenavon will be cared for by staff who are skilled and competent to do their jobs, so they can be assured that their needs will be met. Evidence: We were told that for each morning there are five care staff plus one registered nurse and in the afternoon/evening, four care staff and one registered nurse. Overnight there is one nurse and two care staff. This is appropriate to the numbers and dependency levels of the people who are living in the home. The manager explained that extra staff are arranged when there are events going or peoples needs have significantly increased. The home also employs domestic/maintenance, laundry and catering staff, to meet peoples collective daily living needs. Ten of the 17 care staff have already achieved a national vocational qualification (NVQ) Level 2 in care, and an additional five are working towards NVQ Level 2 (85 are therefore trained). Four staff are doing their level 3 training. This means that people will be looked after by staff who have the necessary skills, are competent and able to meet their needs. The new member of staff stated that they had already started the NVQ 2 in care. The home has robust recruitment procedures in place to ensure that the right people Care Homes for Older People Page 20 of 27 Evidence: are employed at the home. New staff will have had to complete an application form and attend for an interview with the home manager. Two satisfactory written references, POVA1st clearance and CRB disclosures will be obtained for all new recruits. Examination of the personnel files of two recently recruited care assistant confirmed these arrangements. There is currently a stable staff team with little turnover, and no use of agency staff. This means that people will be looked after by staff who are familiar with their care and support needs and who are right for the job. New staff will complete an induction training programme when their employment commences and this will ensure that they are familiar with the homes policies and procedures and are competent in meeting the peoples needs. We looked at the programme and saw that it covered home policies and procedures, mandatory training including fire awareness and manual handling, and principles of care. One staff member spoken to during the inspection visit said that they had been very well supported by the staff team when they first started work at the home and that a senior carer had looked after them whilst settling in at the home. A training matrix is maintained to show staff attendance at mandatory training sessions. Because of the long term absence of the homes trainer, some staff have not received their annual updates in manual handling. The new staff members will have been given instruction by a senior member of staff. The manager is already aware of this shortfall and will be ensuring that when the trainer returns to work in the next couple of weeks that manual handling training is given high priority. A record of training attended is kept for each staff member and a look through these records showed that the staff team have had training in various clinical issues, infection control, sensory deprivation and the management of challenging behaviour to name a few. Information provided in the AQAA stated that only half of the kitchen staff have completed food hygiene training. This is not good enough and all catering and kitchen assistants should hold a food hygiene certificate. Care Homes for Older People Page 21 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. The people who live in this home will find that it is well managed and run in their best interests. It is safe and their welfare will be protected. Evidence: Mrs Denise Worgan has been the registered manager at Glenavon for six years, having previously been home manager in other nursing homes in the Bristol area. She is a qualified nurse and has also completed a level 4 National Vocational Qualification (NVQ) in Management. She has all the skills and experience neccessary to run a care home and provide leadership for the staff team. The manager has a very hands-on management style and at all times, ensures that the people who live in the home remain at the centre of all decision-making. We observed her monitoring the quality of work of care staff during the course of the inspection. Staff who were spoken with during the course of the inspection said that the manager was approachable, that they felt able to make suggestions and could Care Homes for Older People Page 22 of 27 Evidence: discuss any issues about peoples care or home activities. Staff meetings and resident meetings are held on alternate months, and a look at the notes made about the meetings, evidenced that the opinions of others are important and are acted upon. Notes of the most recent residents meeting were displayed in the main hallway. Relatives can attend these meetings, but will always be able to speak to the manager or registered nurses, at any time. The home has consistently demonstrated compliance with the Care Standards Act and the National Minimum Standards. Quality questionnaires were completed in March 2009 and people were asked for their views about the food served, the staff and the care and support they are provided with. In addition the manager completes a number of other audits on a monthly basis to monitor standards of service delivery in the home. The manager submitted the Annual Quality Assurance Assessment (AQAA) as requested prior to this inspection and this gave details of the improvements they have made in the last 12 months, what they feel they could do better and the plans for improvement that they have already decided upon. The AQAA provided clear evidence that the quality of service is being measured and appropriate actions taken to improve further. We were told that a Directors meeting is held on a monthly basis to look at overall performance of the home. The proprietor completes a monitoring visit of the home on a monthly basis and completes a report (called a Reg 26 report). These must continue but do not need to be sent to the Care Quality Commission. Copies of these reports however must be available for inspection at any time when visits are made to the home. All the measures that are taken to monitor standards will ensure that the service remains appropriate to the needs of the people who live there. The home looks after personal monies for most people who live in the home, and maintain hand written records of all transactions in and out of the accounts. These were not checked on this inspection however the system followed has always been satisfactory when checked on previous inspection. We have no reason to think that peoples money is no longer being safeguarded by the home. The home records that were examined were all promptly produced upon request, were well maintained and kept secure in either the managers office or the nurses station. The home is well maintained throughout and no health and safety issues were identified during the course of the inspection. The fire log evidenced that all necessary weekly, monthly and quarterly checks are undertaken. Practice fire drills are held on a regular basis, and staff have a fire video to watch. Formal fire safety training is due again in September 2009. There has been a recent visit by the local Fire Officer who has recommended that the Fire Risk Assessment be reviewed and updated on a more regular basis. The manager and the nominated fire warden are already in the process Care Homes for Older People Page 23 of 27 Evidence: of starting this. All fire doors are kept open with magnetic door devices which are disarmed should the fire alarm system be activated. This evidences that the home takes their responsibility for the health and safety of the people who live there seriously. 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 18 13 The registered person must ensure that all staff receive adult protection refresher training as soon as possible This is so that they they have greater awareness and can safeguard those people in their care. 03/07/2009 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 9 When hand written enteries are made on medication administration charts, these should be checked and counter signed in order to verify. This will eliminate the chance of mistakes being made. 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. 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