Care Home: Hedges House Residential Care Hotel Limited

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What the care home does well This is a care home where residents are well looked after. The management team and staff team work well together so that resident`s needs are met in all areas of care, including their social, medical and cultural needs. Residents spoken to commented on how well they are cared for, they included, "I am highly delighted with the care and support provided by the home in all aspects" "I cannot praise the staff highly enough, there is always someone there when I need them and they are always very cheerful and obliging", "I really like living here", "they`ve always got time for you". Through discussion with staff and from information gathered through questionnaires it was confirmed they have a good knowledge of the individual care needs, social and cultural needs of residents living at the home so that they are not disadvantaged in any way. Staff comments included, "I just enjoy coming to work, I feel I can offer a good service to residents". I have alot of support from my manager and colleagues, "We are really supported by the manager, and if we need anything we just say". Observation of care practices throughout the day confirmed residents are treated with dignity and respect, as well as making sure their right to privacy is respected, by knocking on doors before entering for example. The home is well maintained and comfortable so that people can move around without restrictions. Rooms are personalised with evidence of personal items in place so that it is familiar to them. One resident said, "I`ve got my own things in my room, and I can look out and see what`s going on out there". What has improved since the last inspection? The home is continuing to improve the standards in the environment by decorating the home on a continuous programme, and also by improving the external area of the home by providing a patio area for residents to enjoy during good weather. It is intended the home will be extended to provide additional facilities for residents living at the home. What the care home could do better: The home should continue to develop ways in which people who live at the home or use the service in any way have their thoughts about the service considered. This information could be used by the management team in looking at how they are meeting their stated aims and objectives, and if they could make any changes which may improve the lives of people who use the service. There should always be evidence on all staff files that references have been verified and checked so that people living at the home are protected. CARE HOMES FOR OLDER PEOPLE Hedges House Residential Care Hotel Limited 37-39 Church Road Lytham Lancashire FY8 5LL Lead Inspector Mrs Jackie Riley Unannounced Inspection 09:15 12 December 2007 th X10015.doc Version 1.40 Page 1 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 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hedges House Residential Care Hotel Limited Address 37-39 Church Road Lytham Lancashire FY8 5LL 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) 01253 739930 01253 738087 Hedges House Residential Care Hotel Ltd Ms Michelle Lorraine Neville Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only. Care home only - code PC, to people 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 - Code OP. The maximum number of people who can be accommodated is: 27 Date of last inspection 20th September 2006 Brief Description of the Service: Hedges House provides personal care for up to twenty-seven service users of mixed gender. The home is designed to provide excellent facilities for people who live there. All bedrooms are presently used as single accommodation and all have en suite facilities. The location of the home enables service users to access local amenities, as it is within walking distance of Lytham centre. This home is not registered to provide nursing care. Any medical attention required will be dealt with by the individuals G.P. or by other medical professionals i.e. district nurses, physiotherapist, chiropodist, dentist etc. People who live there are encouraged to maintain their links with the surrounding community and every effort is given to ensure that relationships, hobbies and interests can be pursued. In house activities are arranged and service users are free to participate or not as they wish. Visitors are welcome at any time and the management of the home encourage relatives and friends to be involved in the care planning process. The home offers a varied menu and food for any taste can be incorporated into the menu, as can any dietary or cultural needs. There is a written Statement of Purpose and Service User Guide outlining the home purpose, and the services it will provide to residents. This information is made available to all prospective residents or their relative’s representatives to help them make an informed choice about going to live at the home. Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 5 The present rate of charging is between £342.50 and £472.00. Any additional expenses including chiropody, newspapers and additional toiletries are met by the resident or third party. Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit that took place on the 12/12/07, over a period of approximately 5.0 hours as part of the inspection process. We spoke to the homes owner, registered manager, four staff, four individual residents and visitors to the home. We talked to people using the service, and asked staff about those peoples needs. We also looked at the care plans, records and daily notes for three people, this is called case tracking. We toured the home to look at the environment. During the inspection process time was spent looking at records, moving around the home and talking to people who live, work or visit the home to get an overview of how the home operates on a day to day basis. Comments received during the inspection will be recorded in the main body of the report so that it reflects the overall outcome of the inspection outcome. There were seven survey responses received prior to the site inspection; they included the views of resident’s relatives and staff. There were no surveys returned from GP surgeries. Comments received at the time of the site visit and from the survey questionnaires were very positive about the standard of care and support provided by the staff and management of the home. Records of three members of staff were also examined, as well as discussion with individual staff members on duty at the time of the site visit. What the service does well: This is a care home where residents are well looked after. The management team and staff team work well together so that resident’s needs are met in all areas of care, including their social, medical and cultural needs. Residents spoken to commented on how well they are cared for, they included, “I am highly delighted with the care and support provided by the home in all aspects” “I cannot praise the staff highly enough, there is always someone there when I need them and they are always very cheerful and obliging”, “I really like living here”, “they’ve always got time for you”. Through discussion with staff and from information gathered through questionnaires it was confirmed they have a good knowledge of the individual care needs, social and cultural needs of residents living at the home so that they are not disadvantaged in any way. Staff comments included, “I just enjoy coming to work, I feel I can offer a good service to residents”. I have a Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 7 lot of support from my manager and colleagues, “We are really supported by the manager, and if we need anything we just say”. Observation of care practices throughout the day confirmed residents are treated with dignity and respect, as well as making sure their right to privacy is respected, by knocking on doors before entering for example. The home is well maintained and comfortable so that people can move around without restrictions. Rooms are personalised with evidence of personal items in place so that it is familiar to them. One resident said, “I’ve got my own things in my room, and I can look out and see what’s going on out there”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 8 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 Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission and assessment procedures are very clear and precise to ensure the needs of the residents are met. EVIDENCE: We looked at the homes written literature, which provides information about the home and the services it, provides. The information is currently being reviewed and a more comprehensive version will be introduced in the near future. In addition to written information about the home, the management team have produced a website so that people can also get information from the Internet, which can be quicker than requesting written literature. We looked at the records of three residents. We found they had full assessment information recorded in detail. Resident files seen had in place a social work assessment in instances where funding by the local authority was being made. In other instances there was evidence the home had carried out its own full assessment of need prior to any placement being agreed, so that Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 10 nobody is disadvantaged in how their individual needs are assessed. The manager stated they need to know they can meet the needs of a resident prior to them coming to live at the home. The information on the assessment plans helps care staff at the home to develop a care plan to ensure all health, welfare and social and cultural needs are identified and recorded. A staff member spoken to said, “we take part in the assessment when people are admitted so that we know exactly what a persons needs are”. A resident spoken to confirmed they were involved in the assessment process and able to give their views of the support they required. Another resident spoken to said, “They went through all my health needs before I came, to make sure they knew just what I needed”. There was evidence on the three files seen of residents or their families being invited to be part of the assessment planning and review of the residents needs. Staff members spoken to confirmed they have access to residents assessment plans and could describe in detail individual residents needs The home does not provide intermediate care. Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Promotion of health is taken seriously. Resident’s welfare is closely monitored and health needs are identified and met. EVIDENCE: We found the records of three residents were complete, accurate and had very good information relating to the health and welfare of the individual residents. Significant events had been recorded and followed through so that a competent workforce was meeting the resident’s needs. The care plans were well structured and were being reviewed monthly or whenever a significant event had taken place. Care staff are involved in the process and those spoken to said, “we are trained to record a residents needs, and how they are going to be met, it’s really important to make sure everything is recorded”. A resident said, “they ask about my health and different things so I know they are looking after me”. Health care records showed there is a good liaison between the home and health care professionals including doctors, district nurses, chiropody, and Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 12 optical services, so that residents are not disadvantaged in any way and their individual health needs are met. The records confirmed one instance where a healthcare problem had been highlighted and a quick response from the home meant that it was a good outcome for the resident concerned. Comments included, “when I need any help the staff are always there for me”, “Sometimes when I panic I buzz for help and they are always there to help me”. Records examined confirmed risk assessments have been completed and are reviewed when required and updated reflecting any changes that may have occurred individually and in the environment ensuring the resident’s needs are being monitored. Medication practices observed at lunchtime were safe and good records had been kept ensuring residents health is maintained. The staff team have received training in the area of safe medication practices, so that the system is safe for the protection of users of the service. Some of the staff spoken to said “we have training in meds if we are going to give them out, but some of us don’t want that responsibility” Resident’s dignity and privacy was observed during the visit ensuring residents are treated with respect. This was confirmed by observing staff members knocking on doors before entering rooms, and the way staff talked and responded to residents. One resident spoken to said, “the staff listen to me and what I’ve got to say, they are very helpful”, “ they always knock and give a shout before they come in”. Staff said, “we always respect residents dignity as I expect mine to be”, “we always respect it when people want to be in their own room, it’s their space”, “the staff couldn’t be more helpful to mum, they are always there to help”. Hedges House Residential Care Hotel Limited DS0000069107.V353855.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. EVIDENCE: We spoke to a number of residents who said routines in the home are flexible and they were able to make their own decisions about how they live their lives. Comments included, “there are always things going on, but if you don’t what to be involved you don’t have to”, “I come and go as I please”, “I’ve been very busy with the publication of my book, its back in print now”, “we have all sorts of things going on here, there’s never a dull moment” “ residents have led some really interesting lives, some of them have done some really interesting things and like to talk about it”. We saw residents have in place a varied activity programme but this is flexible and some residents spoken to said, “I prefer to be in my own room, but sometimes I like to join in”. We found there is a choice of activities both in the home and in the community. Some residents commented on enjoying going out independently, some go to church on a regular basis. There are trips to the theatre. As this inspection took place during the pre Christmas period we Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 14 saw there was a range of activities in place at the home including entertainers, special meals, or trips out. A resident we spoke to said, “it’s so busy at this time but its really nice and the staff work hard to make sure we always enjoy ourselves”. “There are many activities provided by the home, from regular keep fit classes, to weekly quizzes. In the summer I went to a show and a garden party. We also went round the illuminations. At Christmas we have a carol service and Christmas party for the residents, with cabaret. We also go to a local hotel for a Christmas dinner and entertainment. Other events are also arranged throughout the year e.g. a trip to a garden centre and to local events” We saw the home provides a varied and balanced diet for residents. We saw the home provides a varied menu, which is designed around resident’s choices and preferences. On the day of the site visit, a resident spoken to preferred to eat in their own room and received a choice of the meals of the day. The resident commented positively on the meals served and said, “they know what my likes and dislikes its always good”, “All the meals are of a high standard. The food served is excellent. We have a three-course meal every day, which always varies. I am very happy with the food provided”. We saw evidence of special dietary needs being taken into account and advice is sought in some instances for specialist diets. We found the home has linked into the local councils taste for life scheme”, which provides advice and guidance in respect of the meeting the nutritional needs of people living in care homes. We found good care planning makes sure the home is promoting equality by treating residents as individuals. Discussion with a resident confirmed the home is taking into account personal hobbies and interests. “I’m always busy, and the staff support me in whatever I do”. Another resident said, “ there are times when I like to be alone and can do this by going to my room which has a lot of personal memories in the way of photos etc”. Hedges House Residential Care Hotel Limited DS0000069107.V353855.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for complaints are handled well and taken seriously ensuring people are listened to. Procedures for reporting abuse were satisfactory ensuring people are adequately protected. EVIDENCE: We saw the home has a detailed complaints procedure, which is made available to all residents on admission and contained in the Statement of Purpose and Service User Guide to ensure they feel protected. Residents spoken to were aware of how to make complaints and felt they would be listened to and acted upon. At the time of the site visit there have been no complaints made to the Commission or the home since the previous inspection. We found the home has a procedure in place for dealing with allegations of abuse. We spoke to the manager and staff who had a good understanding of the procedures to be followed in the event of any allegations or suspicion of abuse or neglect. There was evidence all staff receive training in this area so that they have the knowledge and skills to address any concerns raised in an appropriate manner in accordance with local and national guidance. Staff spoken to said, “we have had training in making sure people are protected and safe”, “I would know what to do if I thought somebody was being mistreated and that would be go straight to the manager”. Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment is safe and clean maintained to a good standard providing comfortable surroundings for the residents. EVIDENCE: We saw the home is very well maintained and decorated to a high standard for the comfort of the users of the service. There is a maintenance employee designated to provide regular maintenance cover to areas of the home both internally and externally so that it is maintained to a good standard and in accordance with health and safety practices. A tour of the home found it to be clean and tidy with no evidence of offensive odours and the home has in place policies and procedures for infection control. Comments received at the time of the visit and from surveys said, “The home is always clean and fresh “,“The home is always spotlessly clean. My room is cleaned on a daily basis and my bed linen changed regularly”, “they’re always Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 17 cleaning and tidying up”. Staff commented on how they have received infection control training and how this is very important in delivering a good standard of care to people. We saw there are policies and guidance for laundry processes and for the control of infection ensuring the home is kept clean, pleasant and hygienic. The home benefits from a continuous programme of decoration for the comfort of the people using the service. One resident commented on how nice it was to be able to have their own things in the room, as it was a ‘home from home’. “I’ve got my own things in my room, and its such a lovely view from here”. We were told it is the intention of the home to replace the current nurse call system with a more up to date version, which will provide an improved service to people using the service. We looked at the bathing facilities available to residents living in the home. We saw they are varied to meet the needs of the people using them. Comments included, “I like to have a soak and the staff help me”, “I can shower myself but if I need help I know I can ask and the staff will be there” Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are procedures in place to make sure staff are recruited in a way, which protects people, however in a few instances there was limited evidence to confirm references had been verified which has the potential to pose a risk to users of the service. Training for staff is good and enables staff to have the skills and competencies for their roles. EVIDENCE: We saw the staff team have worked together at the home for a long time. This was seen to provide a settled environment for the residents who said, “we know them all well her, and they know us”, “All the staff are very friendly and helpful. They always have time to talk to me and if I need anything they are always willing to help”, “I cannot praise the staff highly enough, there is always someone there when I need them and they are always very cheerful and obliging”. We looked at how the home recruits people to work there. We saw there are policies and procedures which make sure all the necessary checks are in place to make sure people working in the home are safe to do so, so that people living there are protected. We saw in most instances references are taken from the previous employer and other character references are sought to help the manager make a decision about somebody’s fitness to work at the home. In one instance there was no evidence a character reference had been Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 19 checked. Through discussion with the manager, we were told all references are verified; it is therefore necessary to make this clear on the records for audit purposes. Comments received from surveys stated, “I was given a full CRB check and had to provide two references which were fully checked before I was allowed to commence work”. We found the home focuses on the need to assist staff in their development to make sure their skills associated with their individual roles are improved upon. There is evidence of staff having access to a range of training, which helps them to develop their skills in looking after people in the care home. Comments included, “As part of my induction I was partnered with an existing member of staff so I could see what I should and shouldn’t do, I also received a manual including everything that was in my induction”. “I have achieved NVQ 2 and am now doing level 3”, Hedges house are always looking at ways of working together and have a diverse range of staff and residents”. “I fell training which I am being given is appropriate and in-depth and really helps me in my work life and helps me to give the best possible care for the residents I am responsible for”. The observations we made showed the staff team work well together as a team and share ideas. We saw staff responding to residents in a sensitive way, and there were always staff in close proximity to residents so they know there is support available whenever they need it. Comments included, “we always have an adequate ratio of staff to residents and most staff have NVQ 2. There is always a member of staff who can meet all of the needs of each resident”. Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed well and systems and policies in place for the protection and safety of staff and residents are good. Lack of a formal quality assurance system, measuring its stated aims and objectives, has the potential to affect the development of the home. EVIDENCE: We found the registered manager has the necessary skills and experience required to support the staff and residents and enable the home to meet its stated purpose and objectives. Staff spoken to say they found the management team to be supportive and they felt provided a clear sense of leadership. Staff comments included “I have a lot of support from my manager and colleagues”, “before we start our Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 21 duty we sit down and discuss what has happened during the day or night”. “the manager is always approachable and helpful”. Residents spoke positively about the management, comments included, “If I had a problem I know I could speak to the manager. She is always very friendly and approachable. She always has time to talk to you and gives me a lot of support and encouragement”, “the manager is always there if you need her, and she always sorts things out for you”. We saw the way the home keeps its financial records are good. They were well maintained and up to date ensuring residents interests are safeguarded. We found that there was little evidence of quality monitoring or quality assurance systems in place. We spoke to the manager about this and were informed this is an area currently under development. The management team are aware of the need to measure their stated aims and objectives so that they can identify areas which may require further development for better outcomes for people who live and work there. The owner of the home is there on a daily basis, and is working with the manager to set up a system for quality assurance. By talking to the residents and staff we found there is an informal way of communicating thoughts and feelings and the regular staff and resident meetings also go towards looking at the quality monitoring processes. Residents and staff spoken to said they felt they could raise any issues, which they felt necessary, without feeling concerned. One staff member commented, “its all open and honest here”. We found the manager focuses on supervision of staff, and sees it as an important way of making sure the staff are carrying out their roles as well as using it as a way of helping them to develop in their roles and to identify any training needs. Inspection of maintenance records confirmed equipment and facilities are being maintained as required by health and safety legislation so that the homes environment is safe for all users of the service. Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 22 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 4 Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 23 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. 1 Refer to Standard OP33 Good Practice Recommendations The home owner and manager should continue to develop a formal quality monitoring system so that the views and users of the service can be audited against its stated aims and objectives to improve outcomes for people. The manager should make sure there is visible evidence on individual files that all references have been verified, so that there is an open and transparent audit trail. 2 OP29 Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hedges House Residential Care Hotel Limited DS0000069107.V353855.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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