Care Home: Gwendoline House

What the care home does well The management and staff team at Gwendoline House have a commitment and drive in wishing to provide a good quality service at the home, ensuring that individuals, their relatives and staff are consulted. There are clear lines of accountability within the home. The matron ensures that no individual is admitted into the home unless there has been a full assessment of their needs and that the home are confident that they are able to support them to maintain their skills and lead a fulfilling life The home is comfortable, homely and well maintained. The house is well furnished and those living at the home have personalised their rooms and showed a sense of pride when talking about `their home`. The home has a good care planning system, which is holistic, and this specifies how identified needs are to be met. Care plans are regularly reviewed and there is an ongoing assessment and monitoring of individuals needs and the service is tailored accordingly. Those living at the home said: "I am very happy living her", "Marion is lovely", "Staff here are my friends". Staff have developed sound relationships with those who live at the home and have a clear understanding of the individual needs, wishes and aspirations of those who live at the home. What has improved since the last inspection? Only one requirement had been made during our last visit to the home undertaken in 2007, this was: In order that residents could feel confident that staff have clear information to support them manual handling assessment must contain clear information of staff action/support, a review of these assessments during our visit found that they contained all of the required information and this requirement had been met. What the care home could do better: No requirements or recommendations were made during this visit. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Gwendoline House 17-19 Pleasant Road Staple Hill South Glos BS16 5JN     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: Odette Coveney     Date: 0 4 0 9 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 28 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 28 Information about the care home Name of care home: Address: Gwendoline House 17-19 Pleasant Road Staple Hill South Glos BS16 5JN 01179571957 F/P01179571957 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Mr Philip Frederick Moss care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is 16 The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category (Code OP) Date of last inspection Brief description of the care home Gwendoline House is a privately owned care home for older people situated in Staple Hill, a residential area of Bristol. It is close to local shops and a bus route. Gwendoline House is a detached property with three floors. The proprietor, Mr Moss, lives and works full time at the home, taking overall responsibility. He concentrates his time mainly on cooking and some paperwork tasks. Mrs Moss is the registered manager and is significantly supported by the senior member of staff, Marian Vargheese, who Care Homes for Older People Page 4 of 28 Over 65 16 0 Brief description of the care home oversees the main management of care to the service users. The property has been extended to provide space for sixteen service users. The communal areas comprise a lounge, dining room and conservatory. All bedrooms are single occupancy and thirteen have en-suite facilities. In addition there are three toilets, two shower rooms and a bathroom. There is a secluded courtyard garden with seating, potted plants and a water feature. There continues to be a warm and cheerful atmosphere in the home and activities are organised on a regular basis. 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 unannounced key inspection took place over 7 hours and was completed in one day. The manager, registered provider and matron were present during the inspection and participated in the process. Evidence was gained from a whole range of different sources including: - Information provided by the home in the Annual Quality Assurance Assessment, Information taken from comment cards, directly speaking with people who live in the home, a review of individuals care records, speaking with care staff and visitors to the home and also an examination of some of the homes records and observation of staff practices and interaction with the residents. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act and to review the quality of the care provision for the individuals living in the home. Care Homes for Older People Page 6 of 28 A good number of comment cards were received prior to the inspection, all contained many favorable comments about the service provided to individuals who live at Gwendoline House. Seven were from people who live at the home, one was from a staff member, and two were from health professionals who visit individuals at the home. Comments made were reviewed during the inspection visit and comments made, maintaining confidentiality, have been shared with the matron and registered provider and these have been incorporated within this inspection report. 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. 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 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 9 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. People who live at Gwendoline House are provided with clear information about the service provided and the terms and conditions of their placement. People can be assured that their needs are fully assessed prior to coming into the home and that staff have the skills and understanding, skills and caring approach in order to support people who choose Gwendoline House as their home. Evidence: The home has a Statement of Purpose and Service Users Guide that is available to people thinking of moving into the home and to provide information for those already living in the home. The documents clearly set out the types of needs that Gwendoline House can cater for. The information within these documents was comprehensive and contained clear information for residents and their relatives about the services and facilities provided at the home and furthermore contained information about the staff and management arrangements at the home, there was also information about the Care Homes for Older People Page 10 of 28 Evidence: admissions process into the home and how to raise issues of concern and showed how these would be responded to. There is a clear process to ensure that the service is able to meet the assessed care needs of prospective people moving to the home. There is an admission procedure, which is included in the statement of purpose. Full assessments of needs were undertaken for the person who was most recently admitted to the home. We reviewed this persons records and saw that the home had maintained clear detailed records in order to support this person in their transition to their new home. We also saw that the home complete a Mental Capacity and Deprevation of Liberties assessment for individuals upon their admission into the home in order to determine the level of support for people required in this area and to establish whether other services are needed for people in order to support them with this aspect of their health. Assessments had been well written and in had been completed in accordance with guidence from recent training undertaken by the matron of the home. The matron told us about the most recent person into the home and told us about this persons admissions process. We saw in this persons records that they were able to visit the home and spend time there before deciding on whether to stay, they had stayed at the home for respite prior to their admission and this provided them with the opportunity to test drive the home prior to making a decision about whether to live there. This person told us that although moving from their own home into residential care had been a difficult decision, that the matron and staff had helped them to settle, staff had supported them well and that they had made friends with other people who lived at the home. Clear contractual arrangements are in place for people living at the home, these contain information about the terms and conditions of the placement and provides information about the fees, and about terms and conditions of the placement, including notice periods. and what the fees do and do not cover. We saw that fees are reviewed on an annual basis, clear information is given to individuals and their relatives about this, with explainations included about the costs incured in providing a residential placement. Care Homes for Older People Page 11 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. Care planning and associated records are well written and people living at Gwendoline House can be confident that staff know their needs and respond accordingly. Staff at the home know residents well and supportive, caring relationships are well established. People are well supported with all aspects of their healthcare, and medication is well managed at the home. Evidence: During this visit we sampled the care and other associated records, such as review notes, daily records and risk assessments. We looked in depth at the records for two people who live at the home. Care plans were excellent in their level of detail and were person centered and written to show that the individual concerned was central to the whole process. Person Centered Care Plans covered ares of individuals care such as; personal hygiene, mobility, daily living ,communication, social needs, personal safety and emotional needs. Records were extremely well written and it was evident that the matron and manager at the home had spent a great deal of time on a Care Homes for Older People Page 12 of 28 Evidence: one to one basis talking with residents in order to gain their trust and find out how they wished to be supported. Records provided detailed information upon which staff would know how and what level of assistance individuals needed. Care plans are kept under constant review and are updated at a minimum once per month, and sooner should peoples needs have changed. After admission the home complete an initial Mental Capacity and Deprivation of Liberties Assessments, these are also completed as part of the main care plan and cover areas such as individuals ability to consent, any restrictions that may be in place in order to protect them and other important considerations to be taken into account had all been recorded; such as, whether there is an existing order under the Mental Capacity Act 1983. The matron told us about the training she had completed about this legislation and told us about the responsibility of balancing the rights of individuals who live at the home and the factors of risks that have to be considered as well as the homes duty of care. The matron demonstrated a good understanding of the homes responsibility in this area and told us of other support services and agencies available to people living at the home should these be required. Those living at the home are registered with a number of different GP practices. Where possible, people are encouraged to retain the services of their family general practitioner. Records are maintained of all contacts with GPs and any other healthcare professionals. We saw that individuals are supported to access primary healthcare services such as the dentist, optician, chiropodist and other more specialist services when a need has been identified. We spoke with the matron about the arrangements in place should there be an outbreak of swine flu at the home, we were informed of the current and proposed infection control measures and were satisfied with the homes response, the matron was well informed. Good relationships have been established with health professionals and district nurses visit and support people in the home on a regular basis. Prior to our visit we received two completed surveys from health professionals who visit people who live at the home they informed us that in their opinion people were well looked after and that prompt action is taken by the home to support people to maintain good health. Relatives we spoke to during our visit said their family members were well looked after and they were always kept informed of any changes, or significant events. This information was also confirmed to us prior to our visit in surveys that had been completed by residents who live at the home and their relatives. Relatives also said that the home look after mum well and we are very happy. In their opinion their relatives health had improved since being in the home and they were confident that support from staff, good nutritious meals and medication and good healthcare were all Care Homes for Older People Page 13 of 28 Evidence: contributory factors to their relatives wellbeing. The home has sound procedures in place for the ordering, receipt, storage, administration and disposal of medicines. Records were well maintained and a random check showed us that a sound system was in place. During the course of our visit the staff team were seen going about their duties in a kind, friendly and courteous manner. They were heard being respectful and polite to residents, using first names to address each individual. People living at the home told us about the care and support given to them by staff at the home, they told us; The staff here are excellent !!!, nothing is too much trouble, they are kindness itself, Staff are so lovely, they help me with everything I need, Staff here are like friends, its like living in one happy family. The home have recorded within individuals records their wishes in the event of the end of their life, the home have supported people well with their end of life care and have ensured that with the support of the community district nursing service people have been treated with dignity, respect and care in a pain free environment. Relatives of people who used to live at the home many years ago still visit. 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. Individuals are supported to participate in social activities. Those living at the home receive a well balanced diet and are offered choices at mealtimes Evidence: Through talking with people who live at the home and examination of daily records it was clear that within the home the routines of daily living are flexible and are tailored to the needs of people living at the home. People told us that they are able to go to bed and get up when they wish, that they are given assistance with their personal care in the way they prefer and that they are able to make choices about how they live their life in the home. People told us that the matron and both Mr and Mrs Moss are available to speak with should they wish to raise any concerns or make suggestions for the home. People said Mr Moss is lovely and nothing is too much trouble for Marion, If I have anything to say I do !!, I have no complaints. During our visit we saw from the visitors book that there are a number of people who visit their friends and family at the home, people told us that their relatives are always made welcome. Prior to our visit we received seven completed surveys from people Care Homes for Older People Page 15 of 28 Evidence: who live at the home, Within the section of what the home does well they told us: Everything is top notch, I am settled and happy, They take good care of us , Relatives reported to us; The home is run very efficiently and I believe it is because it is not too big, the staff make it seem like a family home. A tremendous effort is made to comply with everyones likes and dislikes. The meals are excellent, the staff are always happy and helpful. People at the home are well supported to maintain their religious beliefs and clergy visit people at the home, one relative reported to us: I was very impressed with the matron, Marion understand how religious my mother is and finds the appropriate ways of supporting her. I am quite sure that Marion and the staff take equal, personal care and attention of every other resident. Within individuals records we saw that individuals dietary requirements and likes and dislikes in respect of meal preferences were well recorded. At the day of our visit lunch being served was steak pie with seasonal vegetables, with arctic roll or fresh fruit for dessert, people were offered an alternative should they not want the main choice, people were seen enjoying their lunch. On the day of our visit people were seen enjoying a game of bingo which was being facilitated by the staff, people also told us about musical physiotherapy and about how they enjoy it when a gentleman comes into the home to play an organ. People also told us about a trip to Bath where they enjoyed the shopping and lunch out. Activities and entertainment are provided at the home and people are able to participate or not and is dependent on individuals choice. 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. Everyone is confident that any complaints would be dealt with appropriately. People are protected by staff that are able to recognise abuse and know their duty to report poor practice. Evidence: The home has a complaints procedure and this is displayed in the main entrance area of the home, and is included in the homes statement of purpose. The Care Quality Commission have not received any complaints about the service. We saw that the matron has handled any complaints made to her appropriately and has kept records to show how any concerns have been handled. This means that those living at Gwendoline House and their relatives can be assured that any concerns they have will be listened to and acted upon. There have been no referrals made under protection of vulnerable adults procedures. The matron has demonstrated to us a good knowledge of the procedures to take, should any concerns be raised. The home has a copy of the South Gloucestershire Councils protection of vulnerable adults policy. Discussions with the matron evidenced her knowledge of adult abuse issues and an awareness of her responsibility if they we made aware of any bad practice. We also noted that staff have received training in the protection of vulnerable Care Homes for Older People Page 17 of 28 Evidence: adults and have also completed units in respect of this whilst undertaking a National Vocational Qualification in Care Practice. 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. People at Gwendoline House live in a clean, homely, safe environment. Evidence: Gwendoline House is located within the pleasant area of Staple Hill it is close to local shops and amenities and the shopping are of Kingswood. It is wheelchair accessible. There is a patio area with lots of tubs and hanging baskets at the rear of the house; these were seen to be well tended. Gwendoline House is very comfortable and homely, around the home are fresh plants and flowers, there are nick naks which residents pointed out to us that had a spacial meaning for them, these were in pride of place at the home. Seating was comfortable and furnishing were of a good standard. In walking around the home it was evident that the home is well maintained and provides a safe environment for residents and staff. Since our last visit to the home bedrooms have been redecorated and new furniture has been provided in all bedrooms; The front of the home has been repainted and the home are currently in the process of replacing the boilers in the home. There are adaptations in place throughout the Home and specialist equipment including mobility aid, sensory aids and handrails. Care Homes for Older People Page 19 of 28 Evidence: Toilets are situated in readily accessible parts of the Home near to communal areas and bedrooms. The bathrooms and toilets were clean, and were well stocked with hand towels and soap to help minimize risk from cross infection in the Home. The Home looked clean and tidy in all areas that were viewed. 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. Those living at Gwendoline House are supported by staff who caring are well trained, staff are employed following robust recruitment and selection processes in order to protect those living at the home. Evidence: A strength of Gwendoline House is that there is a good history of retaining staff with a well-established staffing group. There were sufficient numbers of staff on duty at the time of this inspection. Each individual has a key worker to support them with the manager and matron being involved with the overall monitoring of individual care. It was clear that staff have developed relationships with individuals and have worked together with them and others in order to identify the needs of residents and then support the person appropriately. There was information in individual care plans that provided information to guide staff to the appropriate level of support that individuals require. Regular staff meetings are held at the home and appropriate subjects are covered in respect of the service provided at the home and in line with the needs of those living at the home. The training records of staff were reviewed and staff are well supported in this area. Staff are able to request and access a variety of training specific to the service provided and in line with individuals personal development needs. Records seen Care Homes for Older People Page 21 of 28 Evidence: evidence that staff have undertaken training in the following areas: First aid, fire safety, medication competency, food hygiene, protection of vulnerable adults. The achievement of a National Vocational Qualification is well promoted within the home. Time was spent observing staff that were supporting and caring for the people who live at the home. It was noted that staff were very patient and asked residents, rather that deciding for them and encouraged individuals to make choice Information contained within individual staff files were all of a consistent standard. The files for three staff were reviewed; including a recently recruited staff member. All of the required documentation was in place in respect of robust recruitment and selection practices. It was found that all of the checks and records required under Schedule 2 of the Regulations had been complied with, including two references being taken up, a Criminal Record Bureau check and clearance from the register of people deemed unsuitable to work with vulnerable adults had been checked before the staff started working at the home. 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. People living at the home are supported to live in a safe, caring environment due policies, procedures and systems in place and also the commitment of the management team. Evidence: The matron, Marion Vargheese is experienced, appropriately qualified and committed to improving the quality of life for the people who live at the home. People living in the home spoke positively of the care provided. Throughout the inspection Mrs Vargheese demonstrated a commitment to the provision of good quality individualised care packages in the home. We observed many occasions when Mrs Vargheese spent time with the residents, she was supporting and reassuring. Both of the registered providers, Mr and Mrs Moss and the matron Mrs Vargheese have high visibility in the home and gives strong leadership and direction. The management team encourages openness and discussion and all are regarded as people who are respected and who listens. Care Homes for Older People Page 23 of 28 Evidence: Mr and Mrs Moss and the matron fully engaged with us during this visit and were able to locate all of the necessary information and documents easily. This shows that the home has good systems in place and is well run. When we spoke with Mrs Vargheese; she spoke about treating people with dignity and respect and about valuing people as adults. The management and staff have a sound understanding of the diverse needs and wishes of people living at Gwendoline House and spoke of people as individuals. Mrs Vargheese gave a number of examples to us to show how people are given practical assistance and support based on their wishes and told us how people at the home are given reassurance, guidance and comfort and how this impacted on peoples quality of life at the home. Prior to the site visit the Commission received from the registered provider a completed annual quality assurance assessment. The annual quality assurance assessment (AQAA) is a process that is being used for all regulated services from April 2007. The AQAA is in two parts: Part one is a self-assessment, part two is a dataset. It is a legal requirement for all services to return an AQAA to the Commission. The document received from the registered was sufficiently detailed. Within the AQAA the home reported; We continue to provide a safe comfortable homely environment for our service users to live in. A well established management and staff team continue to fully support our service users with their health and social needs through a Person Centered Care Planning and individual daily routines. There is a very good relationship between staff and service users. Comments from our service users say that they are listened to and treated with respect. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that Gwendoline House complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. The fire logbook, record of fire safety training and accident and incident records were found to be accurate and up to date. During our last visit to the service a requirement was made that manual handling assessments must contain detail as to how staff will support residents in this area. During this visit we reviewed these assessments and saw that they contained full and detailed information as needed, including information about the support needed from staff and the equipment needed to ensure they were moved safely. We did not review or discuss the financial viability of the business, it is noted that the home had full occupancy. The matron confirmed to us that no money is held at the home on behalf of individuals who live there. Care Homes for Older People Page 24 of 28 Evidence: Policies and procedures are not always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce risks to people living and working at the home. Staff files also contained evidence of supervision and positive comments were noted in the feedback to staff. Frequency of supervision was generally good and staff had received the required sessions. Areas of discussion included guidelines and policies of the home, individuals expectations and an evaluation of their performance and how this can be developed. Care Homes for Older People Page 25 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 26 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 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 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 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!