Care Home: Haven Rose Rest Home

Similar services:

• St Vincents
• The Cotswold Home
• Winton House
• Rush Court
• Hillyfield Rest Home
• The Maypole Nursing Centre
• The Briars

What the care home does well The food in the home is of good quality and caters for the individual needs and preferences of people living there. Care plans are descriptive and provide good guidance to staff on how individual needs should be addressed. What has improved since the last inspection? At the previous inspection in January 2010 we had made eight requirements and the service had addressed each of these by the time of this inspection. The requirements had related to the need to improve care plans, monitoring peoples health needs, medication, activities, the cleanliness of the home, the Manager`s training, the quality assurance system and staff support and supervision. The level of improvement within the home in the three months since the previous inspection indicates the Manager`s willingness to comply with the regulation process and desire to make improvements to the service. What the care home could do better: Further work needs to be done with the activities in the home to ensure that there is a range of activities to ensure that the needs and wishes of all service users are catered for. The quality assurance systems has improved and now the Manager needs to produce an improvement plan for the service based on the information received during the quality assurance process. the Manager also needs to complete her training. During the inspection we had concerns about razors and combs being left available in a bathroom and that good infection control may not be maintained if people used these after they had been used by others. We have made a requirement in respect of this. Key inspection report Care homes for older people Name: Address: Haven Rose Rest Home 33 Landguard Road Southampton Hants SO15 5DL     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Nick Morrison     Date: 2 3 0 4 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Haven Rose Rest Home 33 Landguard Road Southampton Hants SO15 5DL 02380322999 02380366228 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Haven Rose Residential Care Home Limited Name of registered manager (if applicable) Mrs Shahnaaz Joommun Type of registration: Number of places registered: care home 16 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 16 The registered person may provide the following category of service only: Care home only (PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) Mental disorder, excluding learning disability or dementia (MD) Dementia (DE) Date of last inspection 2 8 1 0 2 0 0 9 16 16 0 Over 65 0 0 16 Care Homes for Older People Page 4 of 29 Brief description of the care home Haven Rose is a large detached property situated in Languard Road in Southampton. It is located in a quiet residential area and is close to local shops and amenities. The registered provider is Haven Rose Residential Care Home Limited and the registered manager is Mrs Shahnaaz Joommun. There are 8 single rooms and 4 double rooms and the home is registered to provide accommodation for up to 16 older people both male and female who have mental health and dementia problems. Care Homes for Older People Page 5 of 29 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: one star adequate 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 report represents a review of all the evidence and information gathered about the service since the previous inspection. This included a site visit that occurred on 23 April 2010 and lasted from 10:30am until 3:00 pm. During this time we toured the premises, looked at four service users files and spoke with two people living in the home. We also met with the Manager and spoke with one other member of staff. All records and relevant documentation referred to in the report were seen on the day of inspection visit. We have also referred to the Providers Annual Quality Assurance Assessment (AQAA) and written responses to our survey from nine people who live in the home, four members of staff and two healthcare professionals. These were sent to us in January 2010 prior to the previous inspection. The service was registered on 8 May 2009. The first inspection occured on 4 August 2009 and eight requirements were made. A further Random Inspection was made on 28 October 2009 where another requirement was made. At the inspection on 28 January 2010 we found that the home had addressed all the Care Homes for Older People Page 6 of 29 previous nine requirements. Eight further requirements were made at the inspection in January 2010 and by the time of this current inspection we have found that the home has addressed these eight requirements. The home shows a willingness to comply with the regulatory process and to improve the service and is working towards achieving and sustaining full compliance. Care Homes for Older People Page 7 of 29 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 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 29 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 29 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. Service users benefit from having their needs assessed prior to moving into the home. Evidence: We looked at the files of one person who had recently been admitted to the home, referred to the homes Annual Quality Assurance Assessment (AQAA) and also to the written responses to our surveys. The AQAA told us that the home enables people to visit the home and to stay for the day or overnight before they make a decision about whether or not they want to move in. The file we looked at showed that a pre-admission assessment was undertaken prior to them moving in so that the home could determine whether or not they could meet their needs. The assessment was undertaken with input from other professionals and included a care management assessment. The assessment was comprehensive and covered all aspects of potential needs the person may have. The Manager confirmed that the person was staying at the home on a trial period Care Homes for Older People Page 10 of 29 Evidence: before deciding whether or not to stay, and while the home was further assessing needs and whether or not the home would be suitable for them. An initial care plan had been put in place but was being added to as the home found out more about the persons needs. During the trial period the home was continuing to liaise with other professionals and had arranged additional staff support in order to meet the persons needs. Eight of the nine service users who responded to our survey told us they were asked if they wanted to move into the home and seven of them told us they had sufficient information about the home before moving in. Both of the healthcare professionals who responded to our survey told us the home assesses people well prior to admission. Care Homes for Older People Page 11 of 29 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. Service users benefit from having their needs identified in a care plan and from having their healthcare needs met. They are protected by the homes medication policies and procedures and are treated with dignity and respect. Evidence: We looked at the files of four people living in the home, discussed issues with the Manager, observed the support people received, spoke with two people living in the home and referred to the homes Annual Quality Assurance Assessment (AQAA) and also to the written responses to our surveys. We also looked at medication records and observed staff administering medication. There had been a requirement from the previous inspection that care plans needed to describe the exact support each person required. At that time care plans did not provide clear instruction to staff, which meant that people may receive their care inconsistently and also that they may lose the independence they had. Previous care plans read, for example, as needs all assistance of one carer with dressing and undressing. The care plans we looked at during this visit had been reworded in a way that provided clearer instruction to staff and supported the maintenance of independence for people living in the home. An Care Homes for Older People Page 12 of 29 Evidence: example of this being needs support getting their right arm into the jumper and then can put the left arm in themselves. This requirement has been met. There were daily recording sheets in place for each person and for each shift. These required staff to record the support each person had received during the shift, their physical and mental well-being, what they had eaten and what they had been doing during the shift. These records were filled in conscientiously by staff and provided a good description of each persons care twice a day. Care plans also contained risk assessments where a need had been identified. The home used a risk screening tool to identify areas where there was a potential risk for each person living there. Where this showed there was a risk a full risk assessment was put in place. Evidence from service user files showed that these risks were kept under regular review. There was a requirement from the previous inspection that the home must contact healthcare services where there is a need to and must monitor peoples healthcare needs. This requirement related to a need being identified on a care plan which had not been referred to the persons GP. At this current inspection we found no healthcare needs that had not been referred to appropriate healthcare professionals. The requirement also related to the fact that, where there was concern about fluid intake for a person, there were no clear and accurate records of how much fluid the person consumed. Records stated, for example, drank well. At this current inspection we found records in peoples care plans which stated, in millilitres, exactly how much fluid had been consumed and separate records had been devised for staff to record this information on. Guidance had also been provided to staff as to how many millilitres a cup contained, so that they could be exact in their recording. This requirement has been met. Service user files showed that staff in the home referred to healthcare professionals when necessary in relation to some concerns such as urine infections, mobility, eyesight tests and communication difficulties. There was also good evidence of liaison with healthcare professionals over specific health problems individual service users had. There had been a requirement from the previous inspection that medication records must be accurate and must record on each occasion exactly how much medication a person had received. This related to the fact that some people in the home had been prescribed medication for pain relief as one or two up to four times a day and no more than eight in any twenty-four hour period. At that time the records did not show Care Homes for Older People Page 13 of 29 Evidence: whether one or two tablets had been administered on each occasion. This meant that if a person asked for more of this medication because of pain they were experiencing, the member of staff would not know whether or not they had already received eight tablets in the previous twenty-four hour period. At this current inspection we found that the Manager had altered the recording system in these instances and that it now required staff to record whether one or two tablets had been administered on each occasion. The requirement also related to the fact that it was not clear for all the people who required as necessary medication how staff decided whether or not the medication was needed. At this current inspection we found that there were care plans in place describing the circumstances in which each person may need the medication. This requirement has now been met. The medication records we saw on the day of the inspection were clear, accurate and up to date. The records included what medication had come into the home, what had been administered and what had been returned to the pharmacy. The records also contained photographs of each person living in the home to decrease the likelihood of medication being given to the wrong person. The medication file contained information for staff on the mediation used in the home and the homes medication policy. The Manager audits the records and the medication in the home on a daily basis to decrease the likelihood of any errors occurring. Medication was stored safely and securely in the home. The homes AQAA told us that they ensure people living there have choices about how they spend their time and that privacy and dignity is maintained for people at all times. All nine of the service users who responded to our survey told us that staff in the home listen to and act on what they say and seven of the nine people told us that staff always treat them well. One of the healthcare professionals identified that one of the things the service does well is that they respect privacy and dignity. Initial assessments had information on each persons preferred form of address and we observed staff using these throughout the day of the inspection visit. We also observed that staff respected peoples privacy Care Homes for Older People Page 14 of 29 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. Service users benefit from being able to exercise choice and control. They also benefit from good support in maintaining contact with friends and families and a good, balanced diet. Activities in the home do not suit all service users. Evidence: We looked at the files of four people who live in the home, referred to the homes Annual Quality Assurance Assessment (AQAA) and written responses to our surveys. We also spoke with two people who live in the home, looked at menus, spoke with the Manager and observed how staff supported people throughout the day. There had been a requirement from the previous inspection that the home must fully assess the social and leisure needs of people living there and provide a programme of activities that reflects these. This was because there were few planned activities and no plan of when different activities will take place. The AQAA had identified that the home needs to improve the range and regularity of activities provided for people living in the home. One of the healthcare professionals who responded to our survey also identified that one of the things the home could do Care Homes for Older People Page 15 of 29 Evidence: better was to ensure there was a social activities structure. During this current inspection we found, from the daily records of the people whose files we looked at, that those people were receiving very low levels of activity and stimulation during the day. However, the overall records of activity within the home showed that planned activities were now in place and other people living in the home were taking part in these. There were also records of occasions where activities had been offered to people but they had declined to take part in them. This included the people whose files we had looked at. The home had begun the process of assessing individual interests of service users and some of the planned activities reflected these. The activities plan needs to develop further in order to ensure that there are activities available in the home which reflect the interests of all the people living in the home. This requirement has been partially met. Risk assessments were in place to support some people living in the home to go out without staff support. This included going to the local shops and going to the Post Office to collect their money. The home arranged transport for some people who went out on their own and there was also support for other people living in the home to attend church services when they wanted to. Service user files showed good evidence that staff in the home supported people to stay in contact with their friends and families and the Manager, in discussion, stated she felt this was an important part of the service provided. All nine of the service users who responded to our survey told us they were able to choose how they spent their time at the home. A healthcare professional told us that what the home did well was to provide a family environment and promote freedom of choice. Our observations throughout the day of the inspection showed that staff in the home were skilled in being able to offer choices to people, give them time to choose and respect their decisions about what they wanted to do. Menus in the home showed that a wide range of food was on offer to people and that different alternatives were always available. Specific diets were catered for, for example where people were diabetic, and the home also catered for peoples ethnic needs and preferences. On the day of the inspection we saw that support was available for people during mealtimes if they required it and that food was served in an appealing manner and in adequate portions. Most service users ate their meal in the dining room and staff ensured that mealtimes were enjoyable and social occasions. Other people chose to have their meals in their room and one person chose to eat in the conservatory. Care Homes for Older People Page 16 of 29 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. Service users benefit from a clear and effective complaints procedure and are protected by the homes adult protection procedures and practices. Evidence: We looked at the homes complaints procedure, spoke with the Manager, referred to the homes Annual Quality Assurance Assessment (AQAA) and to responses to our survey. We also looked at staff training records and referred to information given to us by other professionals. The complaints procedure in the home had been reviewed in March 2009 and staff had signed to say they had read and understood it. Information on how to complain was given to service users and their families when they moved into the home and a copy of the complaints procedure is available in the building. The Manager also told us that residents meetings are used to remind people living in the home about the complaints procedure. All nine of the service users who responded to our survey told us they knew who to speak to if they had a problem and eight of the nine told us they knew how to make a complaint. No complaints had been received since the previous inspection. In discussion with the Manager we found that she was able to demonstrate an understanding of the local safeguarding reporting procedures and how to use them. Staff had received training in protecting vulnerable adults and, in their responses to our survey, four of the four people who responded told us they were aware of what to do if they had concerns about practices in the home. Care Homes for Older People Page 17 of 29 Evidence: There had been no safeguarding issues identified in the home since the previous inspection. Care Homes for Older People Page 18 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users benefit from living in clean, well-maintained environment. Infection control in the home is not fully addressed. Evidence: We walked around the building, spoke with the Manager, referred to the homes Annual Quality Assurance Assessment (AQAA) and to responses to our survey. We also referred to previous reports and our own observations on the day of the inspection. There had been a requirement from the previous inspection that the Manager must ensure a cleaning schedule is in place and that it is closely monitored. This was due to the fact that at the previous inspection the building was not as clean as it should be and did not appear to be cleaned in a systematic way on a regular basis. On the day of this current inspection the Manager was able to show us the cleaning schedule that was in place and the records of her monitoring its effectiveness. The building was much cleaner at the time of this current inspection and we found no concerns about cleanliness. The homes AQAA told us they intended, at some point, to redecorate some of the rooms in the home to make them more pleasant and also intend to replace some of the carpets. Since the previous inspection there had been improvement to the decor of the home. The entrance hall had been painted, along with the stairwell and banisters. The Manager has a plan in place to improve the decor Care Homes for Older People Page 19 of 29 Evidence: in the rest of the building. We observed hand washing facilities throughout the building, along with alcohol gel dispensers which staff, service users and visitors were encouraged to use. The home has infection control procedures in place and staff had received training in infection control practices. In the downstairs bathroom we found combs and razors that did not appear to belong to anyone in particular. This caused concern as people may go into the bathroom and use these after they had been used by someone else, which may result in cross infection. Care Homes for Older People Page 20 of 29 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. Service users benefit from being supported by adequate numbers of sufficiently trained staff and are protected by the homes recruitment policies and practices. Evidence: We looked at the files of two members of staff, spoke with the Manager, referred to the homes Annual Quality Assurance Assessment (AQAA) and to responses to our survey. We also referred to the homes training plan. Staff files showed that all necessary checks were undertaken prior to people being employed in the home. Good records were kept of these. In responses to our survey, all four of the members of staff who responded said they had not been able to work in the home until their pre-employment checks had been received by the Manager. At the time of the previous inspection the home was relying on staff from agencies to address the shortfall of staffing numbers. This was due to some care staff having left, the Deputy Manager having left and the Secretary being on long term leave. By the time of this current inspection the reliance on agency staff had decreased. The home had appointed a new Deputy Manager and the Secretary had returned from leave. In response to our surveys one member of staff said there was always enough staff on duty, one said there usually were and two said there sometimes were. On the day of the inspection visit we did not observe anything that suggested there were insufficient Care Homes for Older People Page 21 of 29 Evidence: numbers of staff to meet peoples needs. Training records seen on the day of the inspection visit demonstrated that staff had received training in medication, safeguarding and mental health. The home has a training plan in place and this had been updated since the previous inspection. Further staff training had taken place since the previous inspection and the Manager keeps clear records of all the training staff have done and when updates are due. . All four of the staff who responded to our survey told us they thought the training they received was relevant, helped them understand how to do their job, kept them up-todate and provided them with enough knowledge. Care Homes for Older People Page 22 of 29 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are protected by the homes financial procedures and by the management of health and safety issues. Service users benefit from living in clean, safe, well-maintained environment and staff receive regular support and supervision. The Manager does not yet posses the qualifications to manage the service. The quality assurance system in the home continues to develop. Evidence: We looked at the management processes in the home, spoke with the Manager, referred to the homes Annual Quality Assurance Assessment (AQAA) and to responses to our survey. We also looked at health and safety records, quality assurance records and staff support and supervision records. There had been a requirement from the previous inspection that the Manager must undertake training in managing care services. The Manager had told us in the AQAA and in discussion at the previous inspection that Care Homes for Older People Page 23 of 29 Evidence: she had previously begun working towards a qualification in managing care homes and was looking at restarting the qualification with another training provider. She had spoken with the new provider on the day of the previous inspection visit to plan an initial meeting. At this current inspection she told us she had decided against the course she was arranging at the time of the previous inspection because it would take two years to complete. She told us she has arranged to begin the course with another training provider who will support her to complete the course in six months. Progress has been with this requirement, but the Manager needs to complete the training without further delay. The home has an effective system in place to ensure that service users money is clearly accounted for and good records are kept. The home has some quality assurance systems in place including sending out questionnaires to service users, residents meetings and monitoring of service provision by the Manager. At the time of the previous inspection these were not coordinated into an overall quality assurance process where information is gathered from a wide range of sources, analysed and then used in producing a development plan for the service which can be implemented, monitored and reviewed. A requirement had been made that the quality assurance system needed further development. By the time of this inspection the Manager was able to show us documentation of how information previously gathered had begun to be collated and analysed with a view to developing an action plan for the service. In discussion the Manager demonstrated a good understanding of quality assurance processes and of how to use information to improve the service in accordance with the views of people who use it. This requirement has been met in that the quality assurance system has been further developed. Further work is needed to ensure the improvement plan for the service is produced and implemented. There had been a requirement from the previous inspection that staff working in the home must receive regular support and supervision. The two staff files we looked at during this current inspection showed that they had received regular support and supervision sessions since the previous inspection. These were face to face meetings with the Manager and followed a set format to promote discussion about each aspect of the persons role and their training and support needs. These were supplemented by observational sessions where the Manager observed the member of staff undertaking a part of their role and provided feedback on their performance. This included activities such as administering medication and undertaking cleaning tasks. Both types of supervision session were recorded. This requirement is met. The AQAA told us that workplace risk assessments are carried out on a regular basis and action taken, where necessary, to ensure the safety of people who live and work in the home. It also told us the Manager undertakes regular inspections of the building to identify any new hazards. On the day of the inspection visit we looked at the Care Homes for Older People Page 24 of 29 Evidence: workplace risk assessments and found they were up to date. We also saw records demonstrating the Managers weekly checks of the building. These were up to date and it was possible to see where issues had been identified and responded to. No Health and Safety issues were identified during the course of the inspection, other than the one identified in the Environment section of this report where razors were left in the bathroom. Care Homes for Older People Page 25 of 29 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 29 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 12 16 The Manager must ensure that all people living in the home have access to stimulating activity that suits their needs and interests To ensure that people receive adequate stimulation 30/07/2010 2 26 13 The Manager must ensure that items that may cause cross contamination if used by more than one person are not left in communal areas To maintain the health and the safety of people living in the home 28/05/2010 3 31 9 The Manager must complete her training without further delay To ensure she has the skills to manage the home in the interests of people who live there 30/11/2010 Care Homes for Older People Page 27 of 29 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 4 33 24 The Manager must produce an annual action and improvement plan in response to the views of service users and other stakeholders To ensure the service develops in response to the views of people who use it 30/07/2010 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 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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