Care Home: Hankham Lodge

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What the care home does well Hankham Lodge is a family owned and run home and employs a stable and committed team of staff, that are well trained and supported. The home is situated in an attractive country location and offers a homely environment for residents to live in. Residents benefit from their own bedrooms most with en-suite facilities and a choice of comfortable communal and private spaces to spend their time. The home has a relaxed and friendly feeling and residents receive care in a respectful and dignified manner. Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Positive comments were received from residents and visitors throughout the inspection, and comments included ‘everything is brilliant’ ‘we are all very well looked after’ ‘the care is excellent’. Residents benefit from a choice of freshly prepared meals each day. Residents have the opportunity to spend their time as they choose. The home encourages and supports people to be as independent as possible and to maintain contact with family, friends and the wider community. The management of the home are inclusive and consult with staff and residents using the information gathered to improve the service. What has improved since the last inspection? This is a new service that has not been inspected before. The new owners have made good progress ensuring the home is being well run and the needs of residents are well attended to, this being their priority. What the care home could do better: This was the first key inspection for this service the change of ownership in February 2009. Although no requirements have been made following this inspection the registered owners have agreed to action a number of shortfalls to ensure the home is run in accordance with the Care Home Regulations 2001. These are documented within this report. During this inspection it was noted that an unregistered small room was being used to accommodate a resident on respite care. The home is registered to accommodate 20 residents and the home was full, although one resident was in hospital. The resident in the unregistered room took the home over its registered numbers. This was a serious matter that constituted a breach of the Care Standards Act 2000. Once this was identified to the owners they promptly addressed the matter and assured that this room would not be used again. Key inspection report CARE HOMES FOR OLDER PEOPLE Hankham Lodge Hankham Hall Road Westham Pevensey East Sussex BN24 5AG Lead Inspector Melanie Freeman Key Unannounced Inspection 14th July 2009 09:20 DS0000073243.V376157.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hankham Lodge Address Hankham Hall Road Westham Pevensey East Sussex BN24 5AG 01323 766555 01323 766000 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Peter Sims Mrs Svetlana Sims Mrs Svetlana Sims Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 20. Date of last inspection New Service Brief Description of the Service: Hankham Lodge is situated in the rural village of Hankham, one mile from Stone Cross and 3 miles from Eastbourne. A local ‘On Demand’ bus service calling at the door enables residents to access the community more readily. The home provides 18 single rooms and one double room that has been partitioned to provide private accommodation. In addition eight bedrooms have en-suite facilities. There are an additional four bathrooms and three toilets with assisted facilities. Hankham Lodge has a well-maintained very attractive garden with views across the Downs, providing a variety of seating and walking areas. There is a dining room and a sitting room, with a conservatory situated on the ground floor and seating area in the hallway, enabling residents to spend time in different communal rooms as they wish. The home provides a passenger lift to enable people to access all private and communal areas. Hankham Lodge is owned by Mr and Mrs Sims who are registered as individuals and run the home between them, with Mrs Sims being the registered manager. Weekly fees range from the funding supplied from the placing authority to those placements that are privately funded which are between £420 to £525 a week, depending on the room occupied. The fees do not include hairdressing, chiropody, telephone use, and any personal toiletries. All outings are included in the fees. Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star. This means the people who use this service experience good quality outcomes. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 uses the term service user to describe those living in care home settings. For the purpose of this report, those living at Hankham Lodge will be referred to as residents. This was this homes first key inspection since the home was registered with new owners in January 2009, and included an unannounced visit to the home on Tuesday 14 July 2009. The allocated inspector spent approximately six hours in the home and was able to discuss matters with the manager who received the inspection feedback at the conclusion of the visit. All the communal areas were seen along with most of the resident’s rooms. A range of documentation was reviewed including the homes service user’s guide, pre-admission assessment procedures, the systems in place for handling complaints and protecting resident’s from harm, staff recruitment files, staff training records, quality assurance systems and some health and safety records. The care documentation pertaining to two residents were reviewed in depth and the inspector ate a midday meal with a group of residents in the dining room. The required Annual Quality Assurance Assessment (AQAA) was completed by the registered owners and returned when requested and was used to inform this inspection report. What the service does well: Hankham Lodge is a family owned and run home and employs a stable and committed team of staff, that are well trained and supported. The home is situated in an attractive country location and offers a homely environment for residents to live in. Residents benefit from their own bedrooms most with en-suite facilities and a choice of comfortable communal and private spaces to spend their time. The home has a relaxed and friendly feeling and residents receive care in a respectful and dignified manner. Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 6 Positive comments were received from residents and visitors throughout the inspection, and comments included ‘everything is brilliant’ ‘we are all very well looked after’ ‘the care is excellent’. Residents benefit from a choice of freshly prepared meals each day. Residents have the opportunity to spend their time as they choose. The home encourages and supports people to be as independent as possible and to maintain contact with family, friends and the wider community. The management of the home are inclusive and consult with staff and residents using the information gathered to improve the service. 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 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. Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Prospective residents receive sufficient information on the home to enable them to make an informed decision over whether the home is the right place for them. The admission procedure allows for the needs of prospective residents to be assessed by the manager before admission. EVIDENCE: The statement of purpose and service user’s guide was available on request and printed off the computer in the office. These documents were informative and are provided to prospective residents following their initial enquiry. Mr Sims explained that these documents are usually displayed in the front entrance area, along with the last inspection report and other useful Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 9 information for people visiting the home. The home also has a website with further in depth information on the home. A resident and relative spoken with confirmed that they had all the information they wanted about the home and costs involved before admission to the home. Records confirmed that residents are fully aware of the contract arrangements and what facilities and services are included in the fees, the terms and conditions of residency and period of notice. An assessment of the admission process included a review of the documentation used in respect of the last two admissions to the home. This demonstrated that the normal practice would be for the manager to fully assess any prospective resident before an admission to the home is progressed. The manager advised that one admission was initiated before an assessment was completed. This however would not be practice for the future. Following the pre-admission assessment confirmation is sent to prospective residents, advising that the home is able to meet their assessed needs. In this way people are not admitted to the home unless they know that the home can meet their needs. Pre- admission assessments can either take place in the care home during a pre-admission visit, or in the hospital or the prospective residents own home. This process ensures that the needs of people can be confirmed and only those residents who needs can be met are admitted. It takes into account not only the resident’s needs but what the home can offer in way of care and support within the environmental limitations. The AQAA confirmed that residents are invited to use the first 4 weeks of their stay as a trial period, ensuring the placement is suitable. Hankham Lodge does not provide intermediate care. Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the 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 individual plans of care set out residents personal and health care needs, although the care documentation needs to reflect a more person centred approach to care, with further attention to detail and specific care needs. Resident’s health care needs are met with the advice and support of community health care professionals. The home’s practice ensures on the whole that resident’s medicines are stored and administered safely. Care is delivered in such a way that promotes and protects the resident’s privacy, dignity and individuality. EVIDENCE: The care documentation pertaining to two residents were reviewed as part of the inspection process, and each of these residents were met with during the inspection visit to the home. Each resident had a plan of care and this set out Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 11 the basic care needs of these individuals. On the whole these were found to be comprehensive covering the basic care needs of residents. They were generated from generic plans and then adapted accordingly and encompassed information generated from the assessment. It was however noted that they did not reflect the individuality of each person, or specific care needs. There was evidence that the plans of care are reviewed and that resident’s or their representative’s views are taken into account. Individual plans of care however need to be dated and signed. Shortfalls with the care plans were discussed with the manager who recognised how they needed to be improved, and confirmed that this would be progressed. Discussion with staff and the daily care records indicated that the staff had a good understanding of residents needs and the standard of care is being delivered in a way that suites the residents, and allows for flexibility. Systems to maintain good communication between staff are in place and include regular meetings where resident care and support can be discussed. All feedback received about the care was positive. Comments included ‘everything is brilliant’ ‘we are all very well looked after’ ‘the care is excellent’. Records, observation and discussion with staff confirmed that the home work closely with the community health care professionals, ensuring their health care needs are identified and responded to quickly. A visiting health care professional confirmed the communication with this home was good and staff were ‘caring’. Routine risks assessments are completed and are used to inform the care and support provided. Medicines are stored in locked cupboards and the supplying pharmacist has been to the home since the change of ownership, to provide advice and guidance on safe medicine administration and storage. Staff confirmed medicines are dispensed into a pot for administration on an individual basis. All records associated with medicines were found to be clear and accurate and supported the view that medicines are administered safely and in accordance with what has been prescribed. The home has a separate controlled drug cupboard. The register was accurate although it was noted that some controlled drugs in the cupboard had not been entered into the register. This shortfall was raised with the manager who agreed to address as a priority. Further information on this matter is available on the CQC Internet within the guidance document The safe management of controlled drugs in care homes. Direct observation confirmed that staff were very kind to residents and encouraged them to maintain their own autonomy, with routines kept to a minimum and choices respected. It was noted that some residents liked to stay in bed until late morning, getting up at their leisure. Staff worked around this preference. The AQAA identified privacy as a high priority and recorded Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 12 how they work to promote this whilst taking account of staff and the need to provide personal care. Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the 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 are supported to lead their lives how they choose. Residents benefit from a relaxed atmosphere where some regular activity is arranged and residents are supported in maintaining relationships with their families and friends. The meals in the home are good offering both choice and variety, and catering for special diets. EVIDENCE: During the inspection visit it was noted that residents were able to spend time as they wanted to. They are encouraged to develop their own individual routines that staff support. Activities have been promoted with the purchase of a mini bus and weekly outings are now a fixed event and are usually made to local venues or an activity group held in Hailsham. Many of the residents are able to direct and Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 14 organise their own entertainment that includes reading, jigsaws, the television and visitors. The garden offers a beautiful environment for residents to enjoy, and includes a summer house. Further activity includes a trained visiting dog, visiting school children and a choir. The new owners are working with staff and residents to develop the activities and entertainment programme in the home. To establish a varied provision that is responsive to what the residents want and to enhance their quality of life. Further seasonal celebrations are planned and the owners are going to involve residents, staff and their relatives in the organisation of these. Residents are encouraged and supported to maintain contact with their family and friends. The home operates an open door policy and residents are able to spend time with their guests in their rooms or in one of the lounges. Visitors are able to come and go freely, with some taking residents out for trips or meals. One visitor said ‘the home is like one family and as a relative I am treated as another family member’. A meal was eaten with residents and this was well presented and was of a good standard. Most residents chose to eat in the dining room, which was attractive and staff were to hand to help, and respond to any comments or requests. The food provided focuses on home cooking and the tables were set out attractively and had the necessary condiments. Mealtimes are not rushed and are seen as a social event that residents can spend as long as they want completing. Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the 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 benefit from an open culture where they are able to express their views, and are confident that any complaint made would be listened to and responded to appropriately. The manager’s overview of the home would ensure that any safeguarding issue raised would be responded to quickly and appropriately. EVIDENCE: Hankham Lodge has a clear complaints procedure that is readily available and displayed throughout the home. Complaint forms that can be used to record any concern and complaint are available in the front entrance hallway along with envelopes that ensure the confidentiality of the complaint. The home is recording and responding to complaints although the complaint records had been mislaid. Discussion took place around holding complaint records securely and ensuring the contents are held in a confidential way. The owners had an open approach to complaints and concerns and were keen to record any concerns raised and respond to them proactively. The manager was aware of the new local procedures and the home had a copy of these. A copy of these is provided to each staff member. It was discussed Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 16 and agreed that the home would have their own procedure that ran along side the local procedures to allow for clarity and ease of use. Records confirmed that staff had either received relevant training or this had been arranged for a future date. Staff recruitment files confirmed that staff have a Protection of Vulnerable Adults (POVA) check completed along with a Criminal Records Bureau check (CRB). Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Whilst residents benefit from the comfortable, clean, and homely environment, further redecoration and furniture replacement is to be progressed to promote an appealing environment throughout. EVIDENCE: Hankham Lodge is a converted property that has been extended and adapted to its present use. It retains a country house style and has level attractive gardens surrounding it. It has a home-like feel and one visitor reflected on the relaxed atmosphere by saying ‘it has a fun atmosphere’. Some redecoration and furniture replacement is evident and improvements are being progressed including curtain and carpet replacement, however the home Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 18 is still in need of general redecoration improvement and replacement of old furniture. The new owners are aware of this, and confirmed a commitment to this improvement both verbally and within the completed AQAA. A written plan for these improvements should be devised to confirm that these are to be addressed in a planned way. As a converted property the home has some physical limitations, with some areas in the home not being accessible to wheelchairs or mobile hoists. These areas are therefore restricted to those residents with a good mobility. The home does have a passenger lift to assist residents in accessing the first floor, and the bathing facilities are assisted. The manager needs to be mindful of who is admitted to the home to ensure the environment is suitable and that residents needs can be met within the home. Bedrooms seen were personalised and suited residents needs and were seen as their own personal, private areas, with staff respecting this. During the inspection the home was found to have a satisfactory standard of cleanliness and hand washing facilities were available at all communal hand washing areas to promote good hand washing practice. The home has a ground floor laundry that has suitable equipment to manage the laundry in the home. The space within this room is limited and staff need to have clear guidelines to follow to ensure best infection control practice is followed at all times. These procedures need to be based on the Department of Health (DOH) guidelines that are available within the home. Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the 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 benefit from being supported by a kind and dedicated team of staff and are protected by the recruitment systems in place. EVIDENCE: At the time of this assessment visit 20 residents were residing at Hankham Lodge, with one further permanent resident being in hospital. A review of the duty rota indicated that staffing levels provide a minimum of three care staff in the morning, with two care staff working in the afternoon and evening. The manager works in addition to these numbers unless shortfalls need to be filled. At night, the home is staffed by one carer who may sleep from 11pm to 5am. The staffing arrangements at night were discussed with the homes owners/manager in depth and the possible change to a waking carer had been raised within the completed AQAA. Contact following the inspection visit confirmed that the night cover is to be changed to provide a waking night carer. It was also agreed that the home would contact the local fire brigade to discuss the fire precaution arrangements at night. Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 20 In addition to care staff the home employs adequate numbers of cooking and domestic staff. Feedback from staff and residents confirmed that there was enough staff to meet the needs of residents at this time and residents said that ‘staff were always available if needed’ ‘the bell is always answered when rung’. The staffing levels need to be kept under review and allow for flexibility in response to changing needs or emergency situations that may arise. All feedback received about the staff working in the home was very positive and comments received included ‘staff are all very nice’ ‘staff are like family friends’. The relationship between staff and residents was seen to be positive and respectful. The staffing team on the whole is stable although some staff have left recently due to changes in their own circumstances. The staff team are well motivated and comfortable with the change of owner one saying ‘since the new owners improvements are being made’. Communication between staff and with the owners is seen as a priority and promoted through verbal and written forms. Regular team meetings are held and staff are being involved in the planned changes to the environment, practice and its management. The recruitment files pertaining to two staff were reviewed as part of the inspection process and on the whole were found to be comprehensive. They included an application form, terms and conditions of employment, evidence of two references and the required Criminal Records Bureau (CRB) and POVA checks on all staff. It was however noted that not all staff had a full employment history on file. It was also recommended that the references received should also record in what capacity the applicant is known in. The owners said that these matters would be addressed. The AQAA recorded that 75 of care staff have achieved a National Vocational Qualification at some level. As mentioned previously the staff team is stable with staff turnover is kept to minimal, this promotes a continuity of care and social network with the residents. Staff training is being well organised and the manager has a training matrix which evidenced the training provided and planned. This confirmed that staff are completing the required mandatory training with additional training to equip staff in meeting resident’s needs. Records seen identified that induction training is provided and this meets ‘skills for care’. Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the 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 benefit from a well motivated manager who ensures a clear ethos and leadership for the home. Quality assurance processes ensure that residents are listened to with their views being responded to. Resident’s financial interests are safeguarded. The health, safety and welfare of residents and staff are generally well promoted. EVIDENCE: Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 22 Mrs Sims is the registered manager and joint owner with her husband Mr Sims. Both work on a daily basis in the home, with Mr Sims providing the administrative support for the home and dealing with maintenance finances and development. The manager is well motivated and saying how much she is enjoying her role within the home. She is completing an appropriate management course and has a National Vocational Qualification in care. The new owners have an inclusive management style and have worked closely with staff since the purchase of the home. Staff have said that they feel well supported, and were pleased with the changes that have been made, that in their opinion is improving the service and care. Regular staff supervision and appraisal has been established. The owners have also established productive links with residents, relatives and visiting professionals, they consider themselves lucky to have the support that they given them. The home has already established systems for receiving direct feedback from residents and their representatives within questionnaires, and there was evidence in the home to confirm that this information has been responded to. These questionnaires have allowed the new owners of the home to establish the current provision of service and to receive some constructive criticism that they were keen to receive so they could respond accordingly. This system is to be further developed to provide a quality monitoring report with additional auditing processes as part of the quality monitoring systems. The AQAA was completed to a high standard and used as an audit and quality improvement tool. The home does not take any responsibility for any of the resident’s finances and most residents look after their own affairs or have an allocated person to do so. Systems have been put in place in relation to the Health and safety of residents, although records relating to these need to be fuller to confirm the risk assessments and safety checks completed and the results of these. Mr Sims agreed to ensure the necessary documentation is retained within the home. Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hankham Lodge DS0000073243.V376157.R01.S.doc Version 5.2 Page 25 Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NNE1 4WH National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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