Care Home: North Clifton Hall Nursing Home

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What the care home does well Potential service users have their needs assessed prior to admission, which means staff, will be able to plan for their individual needs and know how to care for them. Service users have up to date care plans to enable staff to deliver appropriate individualised care and service users are happy with the care they receive. Medication procedures and practises promote service users safety. Service users have the opportunity to participate in recreational activities within the home and maintain social contacts. Service users receive a nutritious and appetising diet with individual preferences being met. Service users feel able to raise concerns and complaints and can be confident that the acting manager will act on them. Staff know how to safeguard service users. The home provides a clean well maintained environment that meets the needs of service users. Service users are supported by competent and qualified staff and are protected by the home`s recruitment policies and practises. There is evidence that the home is run in the best interests of service users and that the acting manager supports a team of staff to deliver safe and effective care. What has improved since the last inspection? An assessment of needs is now carried out prior to a potential service users being admitted to the home. Service users and visitors are fully aware of the complaints procedure and complaints are fully investigated. Unannounced quality auditing visits are now performed each month, service users are interviewed and the homes environment is inspected. A written report is produced in relation to the quality auditing visit. All records in respect of service users are now held securely. What the care home could do better: The registered provided should ensure that service users or representatives of theirs, document consent to the content of care plans. The provision of recreational activities beyond the homes environment could be improved. Some bathroom facilities would benefit from being redecorated.. Key inspection report Care homes for older people Name: Address: North Clifton Hall Nursing Home Main Road North Clifton Newark Nottinghamshire NG23 7AZ     The quality rating for this care home is:   two star good 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: Steve Keeling     Date: 1 4 0 1 2 0 1 0 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) 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 29 Information about the care home Name of care home: Address: North Clifton Hall Nursing Home Main Road North Clifton Newark Nottinghamshire NG23 7AZ 01777228229 01777228100 loyaltycare@btconnect.com loyaltycare@btconnect.com Loyalty Care Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Type of registration: Number of places registered: care home 27 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: The maximum number of service users who can be accommodated is: 27 The registered person may provide the following categories 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 categories: Old age, not falling within any other category - Code OP Dementia - Code DE Physical disability Code PD maximum number of places: 3 Date of last inspection Brief description of the care home North Clifton Hall is an adapted property situated in its own grounds near the village of North Clifton in north Nottinghamshire. Access to local shop or pub facilities is not Care Homes for Older People Page 4 of 29 Over 65 0 27 0 27 0 3 Brief description of the care home possible without transport. There is a long driveway to the main road to reach the bus route to Gainsborough and Newark. The service provides personal and nursing care for up to twenty-seven older people of both sexes, with up to three places for younger adults with a physical disability. A qualified nurse is on duty at all times. There are twenty-five single rooms and two double bedrooms. A passenger lift provides access to the upper floor. There is one lounge and one dining room, which overlook the gardens. There are five toilets and two bathrooms, one with a jacuzzi and a shower room. The gardens provide a tranquil outdoor area for people to enjoy in good weather. There are car parking spaces at the front of the building. The fees range from £410 - £477 per week, these fees do not include hairdressing, chiropody, dental fees, papers or personal clothing. A full Service User Guide is available from the acting manager and this includes the last inspection report. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: 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: The focus of the inspection undertaken by the Quality Care Commission is upon outcomes for people who use the service (service users) and their views on the service provided. The process considers the providers capacity to meet regulatory requirements, minimum standards of practise, and focuses on aspects of service provision that needs further development. One inspector conducted the unannounced visit. The main method of inspection used is called case tracking which involves selecting service users and looking at the quality of care they receive by speaking to them, observation, reading their records and asking staff about their needs. The acting manager and members of staff were spoken with as part of the visit, records relating to medication management was also inspected to form an opinion Care Homes for Older People Page 6 of 29 about the quality of care provided. A partial tour of the building was undertaken which included service users bedrooms and communal areas they frequent to make sure that the environment is homely and safe. A review of all the information we have received about the home since the last key inspection was performed on the 30.03.2009 was considered in planning this visit. We used the Annual Quality Assurance Assessment which was provided by the acting manager, the eight responses from the ten Have Your Say service users questionnaires and four responses to the five staff surveys which were distributed at the home prior to the inspection process. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking Care Homes for Older People Page 8 of 29 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 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Potential service users have their needs assessed prior to admission, which means staff, will be able to plan for their individual needs and know how to care for them. Evidence: Information provided by the registered manager in the Annual Quality Assurance Assessment states A potential service user has a pre-admission assessment completed to ensure we are able to provide for their individual needs.Also as part of this, we encourage families and friends to provide information and life history and we liaise with with other multidisciplinary agencies when required.Potential service users are actively encouraged to visit the home anytime,a brochure can be sent out or provided on their visit or relatives visit. We only accept a service user if we are able to meet all of their needs. If a potential service user was unsure at anytime, we encourage them to come for a day or part of a day to experience the home and stay for a well cooked meal, to appreciate what we can offer. We can also offer a taster break, whereby they can try us out. Care Homes for Older People Page 11 of 29 Evidence: The Have your Say pre inspection questionnaire asked Did you receive enough information to help you decide if this home was the right place for you before you moved in. Seven respondents stated Yes and one respondent stated No. Records showed that service users had undergone a full needs assessment before gaining residency and additional information from Social Services Department is incorporated into the evaluation process when available. Staff confirmed that the needs of all new service users are discussed at staff handovers and that the needs assessments are always available for further reference and guidance. Intermediate care services are not provided at the care home. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users have up to date care plans to enable staff to deliver the appropriate individual care and service users are happy with the care they receive. Medication procedures and practises promote service users safety. Evidence: Information provided by the acting manager in the Annual Quality Assurance Assessment states Care plans are updated monthly or as and when changes are required, the plans are discussed wherever possible with the service user. We have regular visits by the Chiropodist, hairdresser, optician and mobile dentist. The Continence Adviser regularly visits the home, and we have assess to the Community Matron. The Have your Say pre inspection questionnaire asked service users, Do you receive the care and support you need, five respondents stated Always, two respondents stated Usually and one respondent stated Sometimes. The Have your Say pre inspection questionnaire asked service users, Do you Care Homes for Older People Page 13 of 29 Evidence: receive the medical support You need, seven respondents stated Always and one respondent stated Sometimes. Records showed that care plans are developed to address the identified needs of the service users from pre admission assessments. Risk assessments are performed to ensure any identified risks are addressed through the care planning process. The records did not show that service users or their representatives are involved in the care planning process as service users or their representatives had not signed consent to the care planning documentation. The Have your Say pre inspection questionnaire asked service users, Do you receive the medical support You need, seven respondents stated Always and one respondent stated Sometimes. Service users spoken with confirmed that they are able to see their General Practitioner on request and records showed that service users had received additional interventions from community based specialist nurses, community pharmacists and podiatrists as required. Information provided by the acting manager in the Annual Quality Assurance Assessment states All medications are administered by a fully qualified nurse 24 hours a day, our drug policy is accessible at all times and medication is stored in the appropriate way under current legislation. A medication round was briefly observed, the Medication Administration Records (MAR) were maintained effectively and a qualified nurse was administering service users medication in a safe and competent manner. Information provided by the acting manager in the Annual Quality Assurance Assessment states Personal care is carried out with respect and dignity, privacy is paramount. The pre inspection survey asked Do staff listen and act on what you say, five respondents stated Always, one respondent stated Usually and one respondent stated Sometimes. All service users spoken with on the day of the inspection, and a visitor to the home, said that the acting manager and the care staff very are caring and friendly. Service users confirmed that their respect and dignity is always promoted whilst staff perform personal interventions such as assistance wit washing and dressing. Service users also Care Homes for Older People Page 14 of 29 Evidence: confirmed that the routine in the home is very flexible in meeting their needs, thus promoting the service users respect and decisions as to how they spend their days. A service user spoken with in the day of the inspection stated Living here is the next best thing to living at home, if fact it bloody lovely, the staff are great, its like a hotel, I can get up and go to bed when I like, sit up all night watching TV if I want, its great to have breakfast in bed. A visitor confirmed that the staff are welcoming and respectful at all times, and said that he had never witnessed anything that gave him cause for concern and said This is a fantastic place. Through observations of staff and service user interactions throughout the day it was evident that staff were supportive and promoted a relaxed, caring environment thus affording the service users with dignity and choice at all times. Records showed and service users confirmed that a consultation process is in place as service users meeting are performed on a monthly basis. The outcome of the meetings are documented and the results of consultation process are made available to all service users and their representatives to ensure that good practise is maintained and any issues of concern are identified and addressed. Care Homes for Older People Page 15 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users have the opportunity to participate in recreational activities within the home and maintain social contacts. Service users receive a nutritious and appetising diet with individual preferences being met. Evidence: Information provided by the acting manager in the Annual Quality Assurance Assessment states We have an Activities Co-Coordinator, who is also a carer part time. This has helped to improve the social side and help engage service users to participate in groups or individually. We have an in depth personal profile and activity file documenting evidence of service users achievements. We have open anytime visiting, tea and coffee is provided on trays, so that service users feel they are able to provide hospitality, as if they were at home. Meals are provided in various settings. Most service users like to go to the dining room, this helps service users socialise, if service users require a little more privacy and quiet, they can have their meals taken to their room. In summer, some service users prefer to sit outside, and suitable gazebos and patio furniture is available for their use. The service users love the surroundings and wildlife, we have chickens and the new cat called Angel. It brings a whole new meaning at meal times, when the chickens sit on the bay windows looking in. Care Homes for Older People Page 16 of 29 Evidence: The Have your Say pre inspection questionnaire asked service users Does the home arrange activities that you can take part in, seven respondents stated Always and one respondent stated Usually. The social activities programme is on display in the foyer of the home and showed that a good range of activities are provided within the home. Service users and visitors to the home confirmed that the social activities are provided within the home but stated that they would appreciate more trips out into the community. We discussed this issue with the designated social activities coordinator who stated that she is currently raising funds to provide service users with a trip out, possibly to Skegness or a boat trip on the river Trent. The acting manager stated that an open door policy is encouraged at the home and service users family and friends can visit as they wish. A visitor to the home also confirmed the open access and stated that that the staff at the home always make visitors very welcome and said They [staff] are all very nice and I am always made very welcome. The pre inspection survey asked service users Do you like the meals at the home, six respondents stated Always and one respondents stated Usually. Service users said that they are consulted on the menu provision at the home and said The food is lovely, always a choice provided and we can have our meals in our room if we want to, which is nice. A Visitor to the home also stated, The food is always very good. The inspector observed that a good range of fresh fruit and vegetables was incorporated into the service users meals. The meals were well balanced and well presented. Service users also confirmed that they could have a drink whenever they wish and looked forward to meal times. The inspector observed that service users who required support during mealtimes were assisted in a discrete, sensitive and unhurried manner thus ensuring that they could finish their meals comfortably and their respect and dignity was maintained. Care Homes for Older People Page 17 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users feel able to raise concerns and complaints and can be confident that the acting manager will act on them. Staff know how to safeguard service users. Evidence: Information provided by the acting manager in the Annual Quality Assurance Assessment states We pride ourselves on being able to listen to service users and relatives, when issues are raised. We address them in the appropriate way, document and return an outcome resolving issues that need to be addressed urgently. Our brochure and policy folder clearly lays out the procedure to make complaints. Also the CQC complaint procedure is posted in an accessible area as well as the room documentation. Independent Advocacy Services are posted on the notice board at the entrance lobby, for service users and relatives to contact, it is also in the acting managers office if further help is needed. This can also be used to arbitrate if any unresolved grievances occur. The Have your Say pre inspection questionnaire asked service users Is there someone you can speak to informally if you are not happy, and Do you know how to make a complaint, seven respondents stated Yes and one respondent stated No. A complaints procedure is on display in the foyer of the home and service users or their representatives are given the complaints procedure within the Service Users Guide. Service users spoken with said they felt very safe in the home and the staff are Care Homes for Older People Page 18 of 29 Evidence: receptive to their needs and wishes at all times. All service users spoken with said they felt confident that they could report any concerns to the acting manager and she is available when needed to discuss any concerns they might have. We asked a visitor to the home if he knows what to do if he was not happy with the service and would he be confident enough to make a complaint? The visitor said, Yes if I had any concerns I feel that they would be addressed straight away but I nave no concerns at all. The acting manager was not investigating any complaints at the time of the visit. Records showed that the acting manager has received one complaint relating to the service provision at the home since the last unannounced inspection and it was evidenced that the complaint had been recorded and addressed effectively. One safeguarding issued has been referred to Social Services Department for investigation and records showed that the complaint was not substantiated. We spoke to a member of staff to determine her knowledge in relation to promoting the safety of service users. The member of staff confirmed that she had received training in this area and was able detail appropriate actions to be taken should she suspect abuse was happening. Care Homes for Older People Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good 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 very clean well maintained environment that meets the needs of service users. Evidence: Information provided by the acting manager in the Annual Quality Assurance Assessment states Our redecoration programme has worked well. The service users feel comfortable and happy within their own environments. There are no offencive odours, the cleaning staff have undergone further training in the Control of Substances Hazardous to Health (COSHH). Spring cleaning of rooms are done monthly, with daily cleaning and appropriate carpet cleaning, again this is documented and a plan for cleaning is in place. The Have your Say pre inspection questionnaire asked service users Is the home fresh and clean, six respondents stated Always one respondent stated Usually and one respondent stated Sometimes. A variety of communal space is available for service users, which includes a dining room and lounge areas which service users can receive family and friends as they wish. The homes internal environment, which included the dining rooms and the lounge areas, were clean, warm, fresh, well lit and homely throughout. We observed that service users bedrooms are well maintained, clean and fresh and the fixtures and Care Homes for Older People Page 20 of 29 Evidence: fittings are well maintained. Service users said that they are encouraged to personalise their bedrooms with their own furniture and personal possessions if they wish to further promote a homely environment. A nurse call system is fitted in every room to promote the service users safety. The home has equipment and adaptations to meet the individual needs of the service users such as hoists to aid service users with impaired mobility, all of which were maintained effectively. Some bathroom areas would benefit from redecoration and it was confirmed by the acting manager the the issue would be addressed in the homes planned redecoration plan. All the service users spoken with were very satisfied with the standard of cleanliness in the home and confirmed that their bedrooms are cleaned on a daily basis, as are the communal areas. A well-maintained garden area is available for service users use in the summer months and is accessible to service users with impaired mobility. Care Homes for Older People Page 21 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users are supported by competent and qualified staff and are protected by the homes recruitment policies and practises. Evidence: Information provided by the acting manager in the Annual Quality Assurance Assessment states We have successfully recruited staff who are of various ages and family circumstances, that can provide the required staffing levels for the service user needs. We have a small group bank staff to cover busy times, sickness and holiday relief. Some staff have worked at the home for more than 3 years, and this is a good sign that we are able to retain quality staff. Domestic staffing levels have been increased to provide a more robust cleaning schedule. New care staff and cleaners undergo an Induction plan, which incorporates the Common Induction Plan. The Have your Say pre inspection questionnaire asked service users Are staff available when you need them, four respondents stated Always two respondents stated Usually and two respondents stated Sometimes. Staff employed at the home is sufficient to meet the needs of the 19 service users and an appropriate skill mix was evidenced. On the morning of the inspection three carers were on duty, one qualified nurse, the acting manager, an administration officer and three domiciliary staff. All Service users spoken with on the day of the inspection said Care Homes for Older People Page 22 of 29 Evidence: there always appears to be enough staff on duty and staff are always available when needed. We examined a sample of staff recruitment records which showed recruitment practises had been followed as the files contained Protection of Vulnerable Adult checks, Criminal Record Bureau Checks, an application form, two written references and proof of identity. Information provided by the acting manager in the Annual Quality Assurance Assessment shows that the service has exceeded the required 50 of staff trained to NVQ National Vocational Qualification, level two and above as 83 of the care staff have the qualification. A member of staff confirmed that a training programme is provided which includes Moving and Handling, Food Hygiene, Abuse Awareness, Infection Control and First Aid. It was established that training in Health and Safety had not been provided but through discussions with the acting manager it was established that training in this area will be provided on the 19th January 2010. Care Homes for Older People Page 23 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is evidence that the home is run in the best interests of service users and that the acting manager supports a team of staff to deliver safe and effective care. Evidence: Information provided by the acting manager in the Annual Quality Assurance Assessment states We have an open door policy for service users, relatives and staff. Files for staff have improved in their format, and are more accessible for administration purposes. Office administration is up to date with accurate auditing of petty cash and personal finances for service users. The Have your Say pre inspection questionnaire asked service users What do you think the home does well, comments included Everything, if no one from my family comes, there is always someone to talk to and The food is excellent. The acting manager is an experienced Registered General Nurse (RGN) with over 20 years experience within health provision environments, she has been in employment Care Homes for Older People Page 24 of 29 Evidence: at the home since May 2009 and is currently in the process of registering with the Care Quality Commission. Service users, staff and visitors to the home stated that the acting manager is very efficient, approachable and they felt that that the service provision at the home has improved considerably since she commenced her managerial role. Comments made by service users when asked about the managers abilities included What she has done in the few months she has been here has been very good indeed, in fact shes done bloody wonders and She is lovely, really caring and we all feel valued. A member of staff said The change in the place is amazing, she is so approachable, I feel I can confide in her with work as well as personal problems and she would support me. Its a happy ship now, we have a great team spirit. The acting manager demonstrated a clear vision in relation to developments within the home and staff said that the acting manager communicates a clear sense of direction at all times and felt that their opinions are listened to, and valued. Effective quality auditing systems are in place to determine the quality of the service provision and service users are provided with the opportunity to contribute to the development of the home. Information gleaned from the quality auditing processes is correlated by the acting manager and the results are openly available. In addition to to formal quality auditing process, a comments book is provided within the foyer of the home to provide an opportunity for visitors to the home to comment on the quality of care afforded to service users. Efficient systems are on place to ensure service users are protected from financial abuse. Records showed that service users spending money is individually stored within a secure area and all transactions are recorded and receipts are obtained. Staff confirmed that policies and procedures are available at all times and information provided within the Annual Quality Assurance Assessment shows that the policies and procedures are updated annually. Records showed, and staff confirmed, that staff supervisions and appraisals are performed to provide an opportunity to the staff and the acting manager to discuss staff performance and staff training needs. As stated earlier in the report, the home is maintained to a good standard throughout and information supplied by the acting manager within the AQAA evidenced that Care Homes for Older People Page 25 of 29 Evidence: service users health and wellbeing is promoted by effective routine maintenance. Care Homes for Older People Page 26 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 27 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 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 7 The registered provided should ensure that service users or representatives of theirs, consent to the content of their care plans. The provision of recreational activities beyond the homes environment could be reviewed to address the needs of service users. The registered provider should ensure that all bathroom facilities are maintained to a good standard of decorative order. 2 12 3 19 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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