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Care Home: Netherhayes

  • 13 Fore Street Netherhayes Seaton Devon EX12 2LE
  • Tel: 0129721646
  • Fax: 0129724912

Netherhayes is a large 3-storey house situated in the main shopping area of Seaton. It is close to the seafront and very convenient to all local amenities. In order to provide good security the front door is kept locked and the entrance to the home is via a pedestrian `tunnel` from the main shopping area. Even though the home is very close to shops and the seafront it is very quiet and the gardens are tranquil, with lawns flower beds, trees and a duck pond. There are some parking spaces to the rear of the home, or alternatively there is a Pay and Display car park nearby. Accommodation and personal care is provided for up to 28 older individuals who have 0 0 0 needs associated with old age, who may have dementia type illnesses and/or who have physical disabilities. Bedrooms are situated on the ground, first and second floors. There are 2 stair lifts to enable those people with poor mobility to acces all areas of the home. 17 rooms have en suite facilities and 1 room is available for double occupancy. A copy of the most recent inspection report is displayed on the notice board in the home. At the time of this visit fees for the home started at 550 pounds per week.

  • Latitude: 50.705001831055
    Longitude: -3.0710000991821
  • Manager: Mrs Shirley Elizabeth Fitter
  • Price p/w: £500
  • UK
  • Total Capacity: 28
  • Type: Care home only
  • Provider: Adelaide Lodge Care Home LLP
  • Ownership: Private
  • Care Home ID: 11125
Residents Needs:
Dementia, Physical disability, Old age, not falling within any other category

Previous Inspections

This may not be the latest inspection for this service as we are having techinical problems updating from CQC - please check directly on the regulators website for the most recent report; bestcarehome hopes to be back to regular updates shortly.

For extracts, read the latest CQC inspection for Netherhayes.

Key inspection report Care homes for older people Name: Address: Netherhayes Netherhayes 13 Fore Street Seaton Devon EX12 2LE     The quality rating for this care home is:   three star excellent 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: Sue Dewis     Date: 1 8 1 1 2 0 0 9 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 28 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) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Netherhayes Netherhayes 13 Fore Street Seaton Devon EX12 2LE 0129721646 0129724912 carehomesllp@btconnect.com www.netherhayes.co.uk Adelaide Lodge Care Home LLP care home 28 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) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: Date of last inspection Brief description of the care home Netherhayes is a large 3-storey house situated in the main shopping area of Seaton. It is close to the seafront and very convenient to all local amenities. In order to provide good security the front door is kept locked and the entrance to the home is via a pedestrian tunnel from the main shopping area. Even though the home is very close to shops and the seafront it is very quiet and the gardens are tranquil, with lawns flower beds, trees and a duck pond. There are some parking spaces to the rear of the home, or alternatively there is a Pay and Display car park nearby. Accommodation and personal care is provided for up to 28 older individuals who have Care Homes for Older People Page 4 of 28 0 0 0 Over 65 28 28 28 Brief description of the care home needs associated with old age, who may have dementia type illnesses and/or who have physical disabilities. Bedrooms are situated on the ground, first and second floors. There are 2 stair lifts to enable those people with poor mobility to acces all areas of the home. 17 rooms have en suite facilities and 1 room is available for double occupancy. A copy of the most recent inspection report is displayed on the notice board in the home. At the time of this visit fees for the home started at 550 pounds per week. Care Homes for Older People Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: three star excellent service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced visit took place over 8 hours, one day in the middle of November 2009. The home had been notified that a review of the home was due to take place and had been asked to complete and return an AQAA (Annual Quality Assurance Assessment). This shows us how the home has managed the quality of the service provided over the previous year. It also confirms the dates of maintenance of equipment and what policies and procedures are in place. Information from this document was used to write this report. Although only one inspector was present at this visit, throughout the report there will be reference to what we found and what we were told. This is because the report is written on behalf of the Care Quality Commission (CQC). Care Homes for Older People Page 6 of 28 During the visit 3 people were case tracked. This involves looking at peoples individual plans of care, and, where possible speaking with the person and staff who care for them. This enables the Commission to better understand the experience of everyone living at the home. As part of our process CQC likes to ask as many people as possible for their opinion on how the home is run. We sent questionnaires out to some people living at the home, and some staff. At the time of writing the report, responses had been received from 10 people living at the home and 4 staff. Their comments and views have been included in this report and helped us to make a judgement about the service provided. During the inspection 3 people living at the home were spoken with individually, several more on our tour of the home and the interaction between the people living at the home and those who care for them was closely observed. We also spoke with 4 staff, the owner and the manager. A full tour of the communal areas of the building was made and a sample of records was looked at, including medications, care plans, the fire log book and staff files. All key standards were inspected. Care Homes for Older People Page 7 of 28 What the care home does well: What has improved since the last inspection? What they could do better: One requirement was identified at this visit which was the home must ensure that 2 references are obtained for all staff before they are employed by the home. One recommendation has been made and this is to ensure that hand written entries on the MAR (Medication Administration Record) sheets from when extra medication is prescribed is signed by two members of staff. This is good practice to ensure the correct information has been transcribed. There was also some discussion with the manager about moving the focus of care plans away from problems towards peoples strengths, for example looking at what people can do rather than what they cant. Care Homes for Older People Page 8 of 28 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 9 of 28 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The admission procedure ensures that there is a proper assessment prior to people moving into the home, and that they can be assured that their care needs can be met. Evidence: The home takes time to get to know people thinking of moving into the home and their families and representatives. The home gives people a copy of their brochure when an initial enquiry is made. The brochure contains photographs and basic information about the home. The AQAA (Annual Quality Assurance Assessment) submitted by the home states that they plan to amend the brochure to show improvements that have recently been made to the home. There is also a comprehensive Service User Guide and Statement of Purpose providing a wide range of information about the home both for people thinking of moving in and for those already living there. Copies of these documents are available in all bedrooms. Care Homes for Older People Page 11 of 28 Evidence: The manager outlined the homes pre-admission procedure which included visiting the individual to get to know them, to provide them with information about the home, to answer any questions they may have, and to carry out an assessment to ensure the home can meet their needs. Three people were case tracked during this visit and information relating to their admission to the home was looked at, including their initial assessments, care plans and other related information. The files showed that a wide range of relevant information was gathered before the home decided it could meet their needs and before individual decided to move in, including assessments carried out by health and social care professionals. The manager, Shirley Fitter, explained how she takes care to ensure that the home is able to meet peoples needs before agreeing to admit them. She said she also encourages them to visit other homes in order that they can be entirely certain that Netherhayes is the right home for them. During the visit people told us about how they had chosen to live at Netherhayes. Whenever vacancies allow the home offers short stays and respite care. The home does not provide intermediate care. Care Homes for Older People Page 12 of 28 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Everyone who lives at the home has a care plan which provides staff with information to enable them to meet peoples health and personal care needs on a day to day basis. The management of medication is good and helps ensure people are protected from the risk of not receiving their prescribed medication. Evidence: We looked at the care files for three people living in the home. The care files were comprehensive and sections included an initial assessment and a full care plan. The files also contained detailed risk assessments covering a range of topics including falls, moving and handling and bed rails. However, while there was a risk assessment on the use of bed rails, there was no evidence that a risk assessment had been completed on why bed rails were to be used. For example, what behaviour indicated the individual was at risk of falling from their bed. There was good evidence to show that care plans are reviewed monthly and some Care Homes for Older People Page 13 of 28 Evidence: signatures to show that people were involved in reviewing their plans. Care plans set out the persons needs (problems), the goal to be achieved, and the action staff need to take to ensure the needs are met. However, not all areas of the care plans contained detailed directions to staff on how to meet peoples needs for example one plan stated that the individual needs help to dress with certain items but there were no details of what these items might be. There was some discussion with the manager about moving the focus of care plans away from problems towards peoples strengths, for example looking at what people can do rather than what they cant. Staff have received a range of training on health topics including diabetes, mental health, dementia, continence, and skin care. Information about visits from and to health care professionals had been recorded in individual care plans, showing clear evidence that people are supported to maintain access to specialist medical services. These included GPs, chiropodists and dentists. We saw a variety of daily recordings made by staff and these generally showed good evidence that identified needs had been met. Medication administration was well managed and policies and procedures relating to this area were in place. We were told and records show that staff who administer medications have received training that tested their competency. Staff were seen administering medication appropriately. Records show that medicines are counted when received into the home and records were generally well maintained. However, hand written entries on the MAR (Medication Administration Record) sheets from when extra medication had been prescribed had not been signed by two members of staff, which is good practice to ensure the correct information has been transcribed. People are supported to manage their own medication if they choose to. We were told that risk assessments are completed and staff discretely check to ensure medication is taken as prescribed. Secure storage is provided in which medication can be held. All of the people seen during this visit were treated with respect by the staff and their right to privacy was upheld. Personal care was offered in a discreet manner. Staff told us how they respect peoples privacy when helping them with personal care needs. We heard staff speaking with people in a kindly, friendly way. People that we spoke with Care Homes for Older People Page 14 of 28 Evidence: confirmed that staff always treated them with respect. Staff were seen knocking on doors before entering. Everyone has a single room, and personal care tasks are carried out in the privacy of peoples rooms. The hairdressing room also doubles as a medical treatment room where people can choose to receive treatment by the District Nurses or GPs as well as in their bedrooms if they prefer. The home takes every care to ensure people are given the best possible care at the end of their lives. Copies of current good practice guidance issued by the Department of Health and other recent good practice literature is available to staff. The homes own policies and procedures have been carefully reviewed in line with this guidance and staff have received up-to-date training on care of the dying. Advance Care Plans are being completed for everyone so that staff have information on peoples wishes as to how they wish to be cared for at the end of their lives. Care Homes for Older People Page 15 of 28 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A good range of social outings and activities are available, and there is good daily variation for people living in the home. Evidence: There is a good range of activities provided to suit most peoples interests. However, care plans do not provide staff with details of the persons interests or social history. More detailed information would enable staff to ensure peoples social needs were being met, as well as their health and personal care needs. The manager told us that she intends to improve this area of care plans and to increase the amount of activities, entertainments and outings on offer. A monthly timetable of forthcoming outings, entertainments and activities is displayed on the noticeboard. People are supported to attend church if they wish. A monthly newsletter also lets people know what activities are on offer as well as keeping them up to date with other things going on at the home. Where people have taken part in activities and outings this is evidenced on their care plan. The home also keeps a folder containing details of the activities and outings that have been offered to people, as well as many photographs to show how people have Care Homes for Older People Page 16 of 28 Evidence: enjoyed them. On the day of our visit several people went on a pre-Christmas visit to Otter Nurseries. Meetings are held approximately every six weeks for people living at the home, and during these meetings people are consulted over various aspects of their daily lives at the home including activities and menus. Annual meetings are also held with peoples representatives to ensure they also have an input into the running of the home. The manager told us that visitors are welcome at any time and people told us of their many visitors and how welcome they are made to feel. One visitor told us (via a survey form) I sometimes think the staff must get fed up with the sight of me, but in fact I find it is the complete opposite, and I am welcomed at all times. We looked at how people are offered choices during the day. People who we spoke with told us that they chose what time they get up and go to bed and whether they have their breakfast in the dining room or in their own room. The manager and staff told us how people are encouraged to make choices over all aspects of their daily lives, including the time they want to get up, what they want to wear, and what they want to do. We discussed how the home would manage a situation if a person wanted to do something that the home felt was not in their best interests. The manager told us that she would consult with the person, their representatives and social and health care professionals. She also said that she would complete a full and detailed risk assessment. All of this is good practice. The menus were discussed with the cook and she displayed a good knowledge of the likes, dislikes and dietary needs of everyone living at the home. We saw evidence that menus are varied and balanced and we were told that alternatives are always provided if people dont like the main meals on offer. Daily menus are displayed on the dining room tables so that people can let the kitchen know if they dont want a particular meal. People that we spoke with confirmed an alternative was always available. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to ensure people are aware of what daily activities are available and a weekly list of activities is to be given to individuals. Also to arrange more outings - maybe monthly and to improve the sensory equipment available in communal areas. Care Homes for Older People Page 17 of 28 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a good complaints procedure and people can be confident that their concerns will be listened to. Robust procedures are in place to ensure that people are protected from abuse. Evidence: The homes simple complaints procedure is displayed in the hallway, and is also set out in the Statement of Purpose and Service Users Guide given to everyone on admission. We looked at how the home responds to complaints. A record of formal complaints is maintained by the home. Any moans and groans are recorded on the individuals care plan to demonstrate that all issues are taken seriously and addressed by the home. No complaints have been received by the Commission since our last visit. Everyone we spoke with was clear about who they would speak with if they were unhappy about anything and felt sure that their concerns would be dealt with. This was confirmed by everyone who completed a survey form. The home has a range of policies and procedures in place relating to the prevention of abuse. Records show, and staff told us that they had received training in Safeguarding Adults issues. All four staff that we spoke with were able to discuss different forms of abuse and said that they would report any suspicions they had to the manager. They Care Homes for Older People Page 18 of 28 Evidence: were also able to tell us who they would report any concerns to, outside of the home, if necessary. Care Homes for Older People Page 19 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a pleasant, comfortable and safe environment for those living in, working at and visiting the home. Evidence: A full tour of all the communal areas of the home and some of the individual bedrooms were looked at. All areas of the home have been decorated and furnished to a high standard and appeared comfortable and homely. The domestic staff take pride in their work, ensuring that all areas of the home are kept clean and fresh at all times. There is level access to the outside of the premises and the pleasant well maintained garden. There is a coded entry system to the outside doors to ensure the safety of people living there. Those individuals who can leave the home unaided have access to the code. The home has been well maintained both internally and externally. A maintenance person is employed who ensures that all regular maintenance tasks are carried out promptly and that all areas are safe and in good order. All areas of the home were clean, well ventilated and there were no unpleasant odours. All bedrooms are of a good size and have been individually furnished and decorated to a good standard. Finishing touches include attractive bedspreads and co-ordinating Care Homes for Older People Page 20 of 28 Evidence: curtains and good quality carpets. People are encouraged to bring in furniture and personal effects in order to make their rooms personal and homely. Where couples are accommodated the home offers two bedrooms that can be used flexibly to provide a bedroom and private lounge, or two single rooms according to the preferences of the couple. The home has a good range of equipment available including grab rails, handrails and moving and handling equipment. A new Standaid has recently been purchased to increase the level of mobility equipment available. The laundry area has suitable and functional equipment installed. An impervious floor covering is fitted to minimise the risk of cross contamination. Staff confirmed that disposable gloves and aprons were available to them in order to minimise the risk of cross infection and we saw them being used and disposed of appropriately. Staff also confirmed and records show that they have received training in this area. Care Homes for Older People Page 21 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A wide range of training is provided and the numbers and skill mix of staff on duty are sufficient to meet the needs of people currently living at the home. However, recruitment procedures need to be more robust to ensure that people who may be unsuitable to work with vulnerable people are not employed at the home. Evidence: On the day of the visit there were 27 people living at the home. On duty during this time were the manager, the owner, 4 care staff, and 4 ancillary staff (kitchen staff and domestics) plus a secretary and two maintenance people. People that were spoken with felt that there were enough staff at the home to meet their needs. Staff were praised by people living at the home when we spoke with them and one person commented Lovely staff, all very good to me. Another told us (via a survey form) that staff were considerate and always helpful. Staff that we spoke with demonstrated a good awareness and understanding of peoples needs. They were able to describe peoples personal preferences in the way they received care as well as displaying a good knowledge of their individual needs. Three staff files were looked at. Two files contained all the required information including satisfactory CRB (Criminal Records Bureau) checks, two written references Care Homes for Older People Page 22 of 28 Evidence: and proof of identity. However, one file did not contain 2 written references. This does not ensure that people are protected from the risk of harm by staff who may be unsuitable to work with vulnerable adults. Training has a high priority and the home uses the Red Crier system. Using this system staff work through packs on differing subjects then complete a questionnaire which is sent off to Red Crier for marking. Records show and staff confirmed that there is a wide variety of training available including, Fire procedures, Moving and Handling (provided by a trainer working at the home), Food Hygiene, First Aid and Infection Control. Records show that staff are also encouraged to work for NVQs (National Vocational Qualifications) and 13 staff currently have NVQ level 2 or above. All staff have received training in Safeguarding Adults issues and all new staff receive a full induction in line with Skills for Care recommendations. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit indicates that in order to improve the service the home intends to ensure that staff induction training includes one to one abuse training with in-house trainer, to purchase an infection control training video to be used alongside existing literature, to increase dementia care training and to work towards staff feeling more valued though external activities aimed at team building. Care Homes for Older People Page 23 of 28 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed and has robust management systems in place to check the quality of the services and facilities provided. This results in practices that promote and safeguard the health, safety and welfare of people who live and work in the home. Evidence: The home is managed by Shirley Fitter who has many years of relevant experience of working with the elderly. She holds an NVQ level 4 (National Vocational Qualification) and has also obtained the Registered Managers Award (both of these are recommended qualifications for managers of care services). The Managing Director and Director of Care for the home also hold these qualifications. The home is managed efficiently and the manager and staff team work together well. Staff told us (via surveys) that Manager is always approachable if we need to speak to her about anything. We work as a team quite well to give our residents the best possible care. Care Homes for Older People Page 24 of 28 Evidence: The manager told us that there was no-one living at the home that is subject to a deprivation of liberty authorisation and we saw no evidence to show that anyone living at the home is having their liberty deprived without an authorisation. The home has a good range of methods for checking the quality of the care provided by the home. Regular meetings are held, and questionnaires are sent to people living at the home and their relatives in order to obtain their views on the home. The home has a regular newsletter where the results of the questionnaires are published. A monthly Management Review is conducted where every aspect of the home is covered. These quality assurance systems ensure the home is being run in the best interests of the people living there. However, the system could be further improved by the production of a report detailing how the home will address any issues raised and how they will continue to seek to improve the service. The procedure for dealing with individuals finances remains the same. People are encouraged to handle their own financial affairs, with assistance from their family or representatives if required. Very small amounts of cash are held on behalf of a few individuals who are unable or unwilling to hold cash themselves. Regular expenses such as hairdressing are paid for by the home, and the individual or their relative or representative are invoiced each month. The AQAA (Annual Quality Assurance Assessment) submitted prior to the visit, provided evidence that Netherhayes complies with health and safety legislation in relation to maintenance of equipment, storage of hazardous substances, health and safety checks and risk assessments. Policies and procedures are not always inspected during the visit but the information provided on the AQAA helps us form a judgement as to whether the home has the correct policies to keep people living and working at the home safe. Information provided by the home, evidenced that policies and procedures are in place and along with risk assessments are reviewed regularly and updated where necessary, to ensure they remain appropriate and reduce risks to people living and working at the home. So that the risk of burning from hot surfaces is minimised all radiators within the home have now been covered. All windows above ground floor level are fitted with restrictors, in order to minimise the risk of anyone falling from these windows and all taps are fitted with thermostats to minimise the risk of people being scalded. Care Homes for Older People Page 25 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 29 The home must ensure that 2 references are obtained for all staff before they are employed. This is to ensure people who are unsuitable to work with vulnerable people are not employed at the home. 26/02/2010 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 1 9 You are recommended to ensure that hand written entries on the MAR (Medication Administration Record) sheets from when extra medication is prescribed are signed by two members of staff. This is good practice to ensure the correct information has been transcribed. Care Homes for Older People Page 27 of 28 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 28 of 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!

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