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Care Home: Home Of Comfort Nursing Home

  • 17 Victoria Grove Southsea Portsmouth Hampshire PO5 1NF
  • Tel: 02392730063
  • Fax: 02392730063
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Home of Comfort is a care home providing nursing and personal care for 30 ladies over the age of 65 years. The home is owned and administered by The Home of Comfort Charitable Trust and is represented by a management committee, one of whom is the named responsible individual stated on the certificate of registration. The home is located in the pleasant residential area of Southsea, close to Portsmouth city centre and in walking distance from the sea front and local amenities. The home is two converted Victorian houses on three floors with a purpose-built three-storey wing added in the 1960`s. A newer conservatory lounge has been added in recent years. The home has a well-maintained garden that surrounds the home and is accessible to 112008 service users who make use of it in the finer weather. All rooms are single accommodation. There are two shaft lifts installed.

  • Latitude: 50.789001464844
    Longitude: -1.0809999704361
  • Manager: Barbara James
  • Price p/w: ~
  • UK
  • Total Capacity: 30
  • Type: Care home with nursing
  • Provider: The Home of Comfort Charity
  • Ownership: Voluntary
  • Care Home ID: 8539
Residents Needs:
Old age, not falling within any other category

Latest Inspection

This is the latest available inspection report for this service, carried out on 6th May 2009. CQC found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

For extracts, read the latest CQC inspection for Home Of Comfort Nursing Home.

What the care home does well The service users are provided with a warm and homely environment to live in and they tell us that this meets with their needs. The home has a team of long standing staff that have developed and maintained good relationship with the service users. The service users` meals are well managed and meet with their satisfaction. The service users said that they were comfortable and some said they made choices regarding their activities of daily living. There is an internal audit process that looks at the service users` satisfaction. The service is proactive in taking action at any issues raised as part of their reviews. What has improved since the last inspection? There is a process in place to ensure that dietary assessments are completed and food and fluids records are maintained as required. There is a dedicated hours provided for activity and employment of an activity coordinator has been put in place since the last visit. The records of care given and the care plans contain detailed information about the care needs of the service users and how the staff will be meeting these. The service has in place an ongoing training programme for the staff and this included health and safety training as required. There was evidence that the care plans are now being reviewed. There is a complaint log in place that contain details of how complaints/ concerns are managed at the service. These also included any allegation of abuse and reports made. The staff records seen show that the manager ensures that all necessary checks are completed prior to employment. What the care home could do better: The development of assessments and care plans on how choices are offered in relation to the activity of daily living should be developed. The manager has taken action in further developing assessments and care plans since the last inspection. These improvements have been recognised in the report and must be sustained and embedded in practice. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Home Of Comfort Nursing Home 17 Victoria Grove Southsea Portsmouth Hampshire PO5 1NF     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Anita Tengnah     Date: 0 6 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 32 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Home Of Comfort Nursing Home 17 Victoria Grove Southsea Portsmouth Hampshire PO5 1NF 02392730063 02392730063 hocomfort@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : The Home of Comfort Charity care home 30 Number of places (if applicable): Under 65 Over 65 30 old age, not falling within any other category Additional conditions: 0 The maximum number of service users who can be accommodated is 30. The registered person may provide the following category of service only: Care Home with Nursing - Code N to service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP Date of last inspection Brief description of the care home Home of Comfort is a care home providing nursing and personal care for 30 ladies over the age of 65 years. The home is owned and administered by The Home of Comfort Charitable Trust and is represented by a management committee, one of whom is the named responsible individual stated on the certificate of registration. The home is located in the pleasant residential area of Southsea, close to Portsmouth city centre and in walking distance from the sea front and local amenities. The home is two converted Victorian houses on three floors with a purpose-built three-storey wing added in the 1960s. A newer conservatory lounge has been added in recent years. The home has a well-maintained garden that surrounds the home and is accessible to Care Homes for Older People Page 4 of 32 2 1 1 1 2 0 0 8 Brief description of the care home service users who make use of it in the finer weather. All rooms are single accommodation. There are two shaft lifts installed. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: An unannounced inspection visit was undertaken over one day on 6th May 2009 as part of our inspection process. We sent out the Annual Quality Assurance Assessment (AQAA) to the registered person at the service. This is one of the means of collecting data from the service. We also sent out service users and staff surveys to the home to seek their views of the service provision. We spoke to a number of the service users, their relatives and the staff on the day of the visit. We looked at the environment, service users records and care plans and some staff records as maintained at the service and we observed care practices. We have used information as supplied by the home in their AQAA and other information that we have received since the last inspection. Care Homes for Older People Page 6 of 32 The service users had positive comments about the care that they are receiving. These will be reflected in the body of the report as appropriate. We recognise that the home has developed and put in place care plans and assessments and other records of care. The manager also provided us with an improvement plan following the last visit to tell us how the home was planning to meet the requirements we raised. This improvement has started and needs to be sustained and embedded in practice and ensuring that the assessed needs of the service users are appropriately met. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. Care Homes for Older People Page 8 of 32 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 9 of 32 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 10 of 32 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. There is a good pre admission assessment process in place that ensures that the service users are assessed and the home can meet their needs. The manager confirmed that the home does not provide intermediate care. Evidence: As part of this visit we looked at the pre admission records of three service users who had been admitted since the last inspection. These showed that an assessment is carried out prior to moving into the service.The records were detailed and contained information about the peoples needs and support that they will require for the staff to meet those needs. The manager reported that she usually undertook the assessments and this was delegated to a senior member of staff at times. People who responded to us told us Care Homes for Older People Page 11 of 32 Evidence: that they were provided with adequate information prior to moving into the service. The manager stated that people are offered the choice of visiting the home, however due to their frailty this did not always happen. However the service users family visited. Information such as the statement of purpose and the service users guide are made available to the prospective service users. The service does not provide intermediate care but does support people for short term/ respite care. Care Homes for Older People Page 12 of 32 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. There is a process in place and staff have developed appropriate care plans and assessments to demonstrate how the care needs are met. The access to health care is well managed. There is a satisfactory process in place for the management of medication. The service users are treated with respect and receive the support as required. Evidence: These included one service user who was on respite care and two long stay service users with complex nursing care needs. We looked at the care records of there service users as part of this visit. We found that the home has in place assessments and care plans to demonstrate how the service users needs would be met. The assessments included mobility, swallowing, falls, pressure areas, moving and handling, eyesight. The home also recorded the medications that are brought in on admission. Care plans Care Homes for Older People Page 13 of 32 Evidence: are then developed using the information that had been collated. We found that the records in the care plans were detailed and the staff had good information in relation to the persons needs and how these would be met. At the last inspection the registered person was required to ensure that the records of food and fluids are recorded accurately and nutritional assessments are completed. The records we looked at contained thorough nutritional assessments as per Malnutrition Universal Screening Tool (MUST) and this provided staff with details of any supplement that may be required. The staff reviewed the assessments and care plans on a monthly basis or more often as required in order to ensure that the care plans are current and records of these were available. Falls assessments and care plans are developed for the service users as required, these were seen in the records that we looked at. Consents were sought for the use of bedrails following assessments and records of these were maintained. An area that has improved is the detailed records of care/ support that the carers provided to the service users. Night care plans were also available and these contained clear information about the needs of the service users. An area that requires further development is for the service users who are fairly independent and admitted for short term care. We found that in one of the records did not contain adequate details about this persons needs in order to inform staff practices. The care records that we looked at also consisted of assessments for pressure care relief and equipment such as pressure relieving mattresses and cushions were in place. The manager discussed the procedures that were in place relating to the type of pressure mattresses and their settings. These were according to the weights of the service users and the mattresses are adjusted according to these. The manager was taking action to ensure that the service users care plans also contain details of the pressure mattress setting in order that the staff can monitor these at regular intervals. The manager is aware and ensures that the service users receive care and treatment from the Primary Care Trust ( PCT) as required. The staff reported that they have a good relationship with the local surgeries and they were supportive. The manager reported that the community nurses had supported them in the development of pressure ulcers care plans. The plans contained good details of the ulcers and their treatment in order to inform the staffs practices and ensuring that the needs are met. We noted that referrals are made to external agencies and one record included details Care Homes for Older People Page 14 of 32 Evidence: of an assessment and care programme from a physiotherapist. Another person had been assessed as needing a reclining chair in order to assist them to mobilise out of bed. This had not been received as yet and the manager was looking into this at the time of the visit. The home maintained a record of visits and instructions from the multi disciplinary team that the manager said the staff used in monitoring any changes and new advice/ treatment for the service users. We spoke to a number of the service users and two relatives throughout our visit and they were all complimentary regarding the care that they were receiving. They commented that they always received the care and support when they requested and that the staff were very kind and helpful. We looked at the medication management that the home undertook on behalf of the service users. At the last inspection the registered person was required to improve the way that medication was managed. We found at this visit that all medications were stored safely . The home was using the Nomad system of dispensing medicines. We found that the staff maintained clear records of medication administered. All medication was dispensed from the individual prescribed containers as provided. The manager has put in place a record of creams that are applied by the carers. A sample of the Medication Administration Record (MAR) charts that we looked at showed that records of medicines administered were maintained. A record of medication received and disposed of was also available. Development of procedure is needed to ensure that staff maintain a record of any changes in prescription such as from regular to as required. This should include the detail of who authorised the change and the date that this was done. Staff should ensure that as good practice any medication that is transcribed onto the MAR charts contain two signatures. The service users spoken with and interaction observed showed that the staff and the service users had developed and maintained good relationship with each other. The service users were treated with respect and said that they felt safe and the staff were very good. The care practices and records of care given have improved since the last visit. The manager is aware that improvement achieved must be sustained and embedded in practice. Care Homes for Older People Page 15 of 32 Care Homes for Older People Page 16 of 32 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. There is a well planned activity programme in place that received high degree of satisfaction from the service users. The service users are supported well in maintaining contacts with their family and friends. The meals are well managed, offering choice and variety and meet with the overall satisfaction of the service users. Evidence: The AQAA states that the home has increased the dedicated activities co ordinator hours in order to meet the social and recreational needs of the service users. There has also been an increase in social gathering where the service users relatives and friends can participate. During this visit we found that he home has employed a staff member who works for twenty -four hours per week as the activity coordinator. A planned activity programme was available at the service. We spoke to a number of the service users about the activities and people were complimentary about the varied activities that were Care Homes for Older People Page 17 of 32 Evidence: available. Some of the service users told us about the plant pots that they had painted and they have been growing sunflower seeds. Other ladies told us about the art class and showed us their paintings that are displayed in the dining room. Comments were we have a lot of fun. The activity coordinator talked about the reading from a wartime diary that the service users also enjoyed and they told their own stories of the wartime events. It was evident from the comments we received and the photos album that the activity for the service users were structured and has improved form the last visit. The activities were being developed and sometimes quite innovative such as bringing in snow from outside so that the service users could build a snowman. We noted that the home maintained records of activities and these also included 1:1 session with people who are unable to partake or choose not to join in group activities. We observed the Church service on the day of the visit, this usually takes place on a monthly basis with the support of the local diocese. The service was well attended and the service users we spoke with afterward said that they looked forward to this and they always enjoyed the service. Comment included that there are lots of activities available during the week such as games, baking biscuits, cake and making table decoration for the Easter party. The home has an open visiting policy and the records of visitors, as maintained at the service indicated that people visited at all times of day. We spoke to two relatives at the time of the visit and they said that they are always made welcome and the service users always look well cared for. One of the service users commented that following a long stay in hospital this was the best place to live and the staff were attentive and they were well looked after. A relative commented that the service users have very good care and are supported in maintain their personal appearance including nails painting as they chose. There is a planned menu and choices are offered. All the six service users we spoke to told us that the meals are always very nice. We noted that the service users were regularly offered and supported with hot and cold drinks throughout the day of the visit. We observed the lunch time meal that the majority of the service users having their meals in the main dining room. They told us that they enjoyed the food provided and Care Homes for Older People Page 18 of 32 Evidence: also to meet with their friends. Meals were well managed and The meals looked well balanced, varied, freshly cooked and nicely presented. We spoke to six service users at lunchtime and they all said that the meals were very good and no complaint. We observed that the staff were available top offer the service users support with their meals and lunchtime meal was taken in a leisurely manner. Care Homes for Older People Page 19 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaint process at the home is good and the service users are confident that their concerns will be looked into. Information and records relating to safeguarding were satisfactory. Evidence: The service has a complaint procedure that is displayed in the entrance, the service users that we spoke to said that they would approach the manager/ matron if they had any concerns. They all wanted to stress to us that they did not have anything to complain about and they were happy with the care that they were receiving. There is also a complaint log in place that records concerns and complaints received. The log seen at the time of the visit gave details of the concerns, action that the manager has taken and whether these had been resolved. A record of complaints that had been investigated as safeguarding was also available as required. It was evident from the records maintained at the home that the manager is proactive and made referrals to external authorities as appropriate. Following the last visit the registered person was required to have in place a record of all complaints made and the action taken in respect of any such complaint. This has been complied with from evidence seen at the time of this visit. Care Homes for Older People Page 20 of 32 Evidence: The home has in place the recent guidance from the Portsmouth City Council in relation to the safeguarding protocol. The manager reported that this is used in conjunction with the homes procedures. The manager stated that she had completed training in safeguarding with the city council and this training is cascaded to the staff. Care Homes for Older People Page 21 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service users are accommodated in a warm, homely environment that meets their needs. There is an infection control procedure in place and practices observed supported this. Evidence: The AQAA states that furniture that has been identified as poor in quality has been replaced following their audit. The service was also replacing the mattresses so that all beds will eventually have medium to high pressure relieving mattresses as standard. We looked at a number of the service users bedrooms, communal lounge, bathrooms, dining room, kitchen and the laundry as part of this visit . The home was warm and clean and in good decorative order and furnishing appropriate to the service users needs. It was evident that there is an ongoing programme of refurbishment to ensure that the environment meets the needs of the service users. The manager was aware of one area with some malodour and is looking at addressing this. The service users reported that they spent as much time in their bedrooms as they preferred. The bedrooms were personalised and it was evident that people are supported to bring with them items of personal belongings on admission. Care Homes for Older People Page 22 of 32 Evidence: All those who responded say that the home is always fresh and clean Comment from a service user was I have everything I need in here. Equipment and aids were available to support and maintain the service users independence as needed. The manager reported that action regarding storage of equipment is looked regularly in order to ensure that the home does not have a cluttered feel and these equipments are stored safely. Infection control procedures were in place and the staff we spoke to and practice observed during the visit indicated that they followed the procedures. Protective equipments such as gloves and aprons were available to the staff. The home has a laundry where all the service users laundry was undertaken internally. The laundry staff reported that there is regular review of the service users laundry to ensure that they are replaced as required. Hand washing facility and flooring in the laundry room were satisfactory. Care Homes for Older People Page 23 of 32 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. There is adequate staff to meet the current needs of the service users. The recruitment process is good and the manager ensures that all checks are completed prior to employment as required. There is an ongoing training programme in place to support the staff in their work. Evidence: We looked at the duty rosters as maintained at the service. This showed that there is a roster for the nurses and carers and a separate one for the ancillary staff. This ensured that the care hours are not eroded domestic tasks. The manager stated that there are two trained nurses and six carers on the early shift. The afternoon shift had one trained and four carers with an overlap of a trained nurse until five pm during the week. Night duty had one trained staff and two carers. The staff reported that a couple of them started work at six in the morning to assist the service users and with early morning drinks and this worked well. The AQAA states that the manager has recently recruited two trained staff with mental health training and their skills/ experience would be useful in raising awareness and Care Homes for Older People Page 24 of 32 Evidence: dementia care at the service. Comments from the service users and the staff were that they had adequate staff to meet the needs of the service users. It was evident from the interaction observed that the staff and the service users had developed good relationship with each other. One person said you do not have to wait long when they rang their call bell. Another comment was the staff do their best and always help. One service user told us that they sometimes wanted to remain a bit longer in bed, however the staff do not allow for this and they required two staff and needed to be hoisted. This was brought to the attention of the manager and she will be looking into and take action including raising staff awareness on choices in care plan records. We looked at the recruitment that the home has in place to ensure that this was appropriate and did not put people at risk. At the last visit the registered person was required to ensure that all necessary staff checks are completed prior to them starting work. We looked at the records for two newly recruited staff since the last inspection. We found that all new staff completed an application form and references were sought and these were available in their records. The manager also undertook Nursing and Midwifery Council (NMC) checks as required for the registered nurses to ensure that their registration is current and kept records of these. Other checks such as Criminal Record Bureau (CRB) and POVA first checks were also completed prior to employment. The home has an induction programme in place for the new staff and records of these were seen at the time of the visit. The manager stated that an induction for the trained staff was also available that covered the different roles and responsibilities. There is an ongoing training programme in place for all the staff to ensure that they have the appropriate training to support them in their work. The last inspection report required the registered person to ensure that mandatory health and safety and induction training was available for all the staff. Information we have received indicates that seven staff have completed the nominated first aid course. Three other staff were undertaking the course. All the staff are currently undertaking the dementia care course with Guildford college and were hoping Care Homes for Older People Page 25 of 32 Evidence: to finish this in July 09. The training programme include ongoing update and training in fire safety, infection control and moving and handling. Care Homes for Older People Page 26 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a registered manager and a stable management structure. The manager has clear lines of responsibility for the service. The internal audit and the system for management of the service users personal allowance is good. The home has in place a system to manage the health and safety of the service users. Evidence: The home has a registered manager who has day to day management responsibility for the service. The manager is a registered nurse and has also completed the NVQ training at level 4. The staff and the service users we spoke to were complimentary about the manager and the support that they receive. The manager carried out monthly audits on medication, admission and nursing audits for policies and procedures. Care Homes for Older People Page 27 of 32 Evidence: Comments included The office door is always open and you can just pop in. Matron always takes time to listen to us. There is an internal audit system in place that included regular staff meetings. The service has completed an audit of the service users views in January 09. Positive comments were received regarding the care and facilities at the service. We also noticed that there was a large number of compliments cards from the service users and their families. The responsible individual completed monthly visits to the service and looked at the care delivery and as part of their internal audit. Reports of these were given to the manager and records maintained at the service. A visitor who arrived on the day of the visit was full of praise regarding the care that the manager and staff had provided to their mother who had been a resident at the home. The manager reported that they were not appointees for any of the service users. the home dealt with the personal allowances for some of the service users. We looked at a sample of this and this showed that accurate records were maintained of all transactions. The moneys were kept separately and a random sample looked at were accurate to the records maintained. Receipts of transactions were maintained for items such as chiropody, newspapers, toiletries as required. We observed that the manager has developed and put in place a supervision programme for the staff to ensure that staff practices are monitored as part of their work. The manager stated that the registered nurses are responsible for supervising the carers and this worked well. The AQAA states that there is an ongoing programme for the servicing of equipment to ensure that they remain in good working order and safe. The environmental health officer attended the home in October 08 and the home passed the kitchen inspection. The heating system and emergency lighting checks were completed in November 2008. Information from the AQAA shows that the homes policies and procedures were reviewed during last year. The environment would benefit from regular reviews of storage equipment such as wheelchairs and hoists and some upgrading of old chairs to ensure that these are maintained in good state of repair and safely. Care Homes for Older People Page 28 of 32 Care Homes for Older People Page 29 of 32 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 30 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 32 of 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!

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