Care Home: Pelham Lodge Residential Home

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What the care home does well The management and staff encourage residents to see the home as their own home. It provides a very well maintained, safe, comfortable, attractive home which has all the specialist equipment and adaptations needed to meet individual residents needs. All of the completed comments cards received from residents reported positively on their experiences living within the home. Staff demonstrate their commitment to achieving best outcomes for residents. Staff stated they expressed job satisfaction and confidence in the management of the home. Residents who spoke to us confirmed in their own words that they receive a good quality of care from staff who are courteous, respectful, communicate well, are trained and experienced and deliver care in a individualised and professional manner. Several residents spoke highly of the care staff and felt that they enjoyed the activities they participated in and liked the home they lived in. What has improved since the last inspection? It was evident through the inspection process that the home is taking steps to improve the standards of care. Improvements were noted in respect of all of the identified areas from the last inspection. What the care home could do better: The inspection identified several areas that were in need of being addressed. The management of the home has recognised the shortfalls and has indicated a willingness to work with the Commission to ensure that any shortfalls are addressed. The main areas that were identified were :The home`s care plans do not currently use a socially lead model. From the care plans viewed they were of a medical / clinical approach. The plan of care needs to better evidence social and personal goals including hopes, goals and aspirations where possible, to better evidence the current support given to residents at the home. An appointed person of the registered provider of the home does not regularly visit the home and complete what is known as a Regulation 26 visit. This requires the provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. The manager confirmed that the home has a quality assurance process in place that measures the quality of care given and that the views of residents are included. However this is not formalised as described above. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Pelham Lodge Residential Home 52 Pelham Road Gravesend Kent DA11 0HZ     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: Robert Pettiford     Date: 1 3 0 1 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. the things that people have said are important to them: They reflect 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 28 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.csci.org.uk Internet address Care Homes for Older People Page 3 of 28 Information about the care home Name of care home: Address: Pelham Lodge Residential Home 52 Pelham Road Gravesend Kent DA11 0HZ 01474334956 Telephone number: Fax number: Email address: Provider web address: pelham_lodge@hotmail.com Name of registered provider(s): Name of registered manager (if applicable) Mrs Balbir Kaur Dosanjh Type of registration: Number of places registered: Pelham Lodge Limited care home 10 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Pelham Lodge is registered to provide care and accommodation for up to 10 older people. The premises are close to Gravesend town centre with public transport facilities nearby. Limited car parking space is available for visitors at the front of the building. Residents bedroom accommodation is on the ground and first floor. There is a stair lift to the first floor for residents use. The home does not provide a passenger lift. Each service user has a single bedroom, which is equipped with en-suite facilities (some including a shower unit). The garden at the rear of the property is suitable for use by frail older people. The owner/manager is a registered nurse and has completed the registered managers award. The home employs care staff working a roster, which provides 24-hour cover. The home does not offer nursing facilities. Care staff also undertakes catering and cleaning duties in the home. Current fees range from GBP334 - GBP395 per week according to assessed personal need. Care Homes for Older People Page 4 of 28 Over 65 10 0 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: 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 inspection took place at 9:00AM on 12th January 2009 We agreed and explained the inspection process with the registered manager. The focus of the inspection was to assess the home in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Older Persons. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. We used a varied method of gathering evidence to complete this inspection, pre inspection information such as the previous report and discussion and correspondence Care Homes for Older People Page 6 of 28 with the registered provider/manager was used in the planning process. This was to support us to explore any issues of concern and verify practise and service provision. The home had completed an annual quality assurance assessment questionnaire (AQAA). This provided us with information relating to What the agency considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. The judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the Commission to be able to make an informed decision about outcome areas. Further information can be found on the Commissions website with regards to information on KLORAs and AQAAs. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. Other areas viewed included risk assessments, pre-admission assessments, rotas, and training records. In addition an environmental tour took place. We identified several residents for case tracking (a review of the level of care and support needed, and if it is being provided in a way that treats them with respect and dignity). 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. The report of this inspection is available from our website www.csci.org.uk. You can get Care Homes for Older People Page 8 of 28 printed copies from enquiries@csci.gsi.gov.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. Residents know that their needs will be properly assessed prior to moving to the home. Intermediate care is not provided. Evidence: The standard relating to the assessment of residents prior to them moving into the home was met from the previous inspection. No evidence or intelligence would suggest that the process does not continue to meet with the required standard. Records showed that residents have an assessment, which identifies their individual needs prior to or on admission to the home. This is then reflected into the care plans and these are developed in agreement with the individual where possible. The assessment focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet the needs of the individual. Care Homes for Older People Page 11 of 28 Evidence: The AQAA also confirmed detailed information with regard to ensuring that the home can meet the needs of residents. The AQAA states a holistic assessment is carried out to ensure that all care needs will be met before admission. A devised assessment tool is used from the standex documentation system. Home visits are encouraged and a guided tour of the premises is given. The assessment process as shown in the AQAA recognises cultural needs and the importance of promoting equality and diversity rather than just meeting needs in a reactive manner. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents benefit from having individual plans that identify their physical and medical needs and provide the support they need, but not enough detail was given to social and personal goals. Residents can feel confident that they are fully supported with their healthcare needs. Residents can be confident that they will be treated with respect and dignity and their rights to make decisions about their lives is respected and they have the opportunity to be consulted on, participate in, all aspects of life within the home as they wish or their capacity allows. Residents can feel overall confident that the homes policy and procedures with regard to the administration and dispensing of medication is sound. Evidence: The staff of the home are strongly committed to supporting all residents including Care Homes for Older People Page 13 of 28 Evidence: those to make informed decisions, understand the range of options which are available to them and have the right to take responsible risks. Evidence of this was gathered through taking to the residents, staff, and the manager. We discussed with the manager the care records relating to several residents at Pelham Lodge. In the care plans viewed there were guidelines in respect to support needed. The home undertakes regular reviews. Formal reviews involving significant professionals where possible are also undertaken. The homes care plans do not currently use a socially lead model. From the care plans viewed they were of a medical / clinical approach. The plan of care needs to better evidence social and personal goals including hopes, goals and aspirations where possible, to better evidence the current support given to residents at the home. We viewed a sample of care records and specific health care records relating to several residents. Records viewed confirmed residents had access to a range of health care input as and when required but not as part of regular health checks. This included access to their chosen G.P (where possible), Dentist, Optician and Chiropodist in addition to identified specialist health care input. The Home facilitates residents keeping hospital appointments and seeing their own GP. It is evident through talking to members of staff at the home that the wellbeing of the residents is of a high priority and that staff are pro-active in maintaining and supporting residents with their needs in order to maintain their quality of life. This was confirmed in discussions with many of the residents who lived at the home a relative and feedback received from comment cards returned. Risk assessments were reviewed within the home and discussed with the manager. Assessments seen detailed how to support residents to minimise risks for personal safety and had been updated and reviewed. We visited the home at 9:00AM. During the inspection we noted that residents were seen eating their breakfast and making choices about their lives and were seen to be part of the decision process as their capacity allowed. A relaxed atmosphere was noted with the residents taking to staff. We viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of Medication within the home. The manager confirmed that all staff who dispense medication have received the appropriate training. The inspection of the homes system for storage and the administration of medication Care Homes for Older People Page 14 of 28 Evidence: brought to light only one concern. It was observed during the inspection that a staff member who was administering medication that she was signing the record sheet prior to giving the medication. This was brought to the attention of the manager who later spoke to the staff member and made assurances that she would make it clear to all staff that this is not safe practise. The AQAA showed that improvements had been made since the last inspection in that medication storage was reviewed and a locked metal medicine cupboard in now installed in the office. Medication is now transported downstairs to the communal living area in a locked container where it is then administered to the residents. After dispensing medication is safely returned back to the locked cupboard in the office. All prescribed creams that residents have stored in their rooms are now stored in the lockable facilities provided. Residents have been informed the importance of doing this. No statutory requirements in respect of medication have been made at this time. Daily records were not wholly comprentaneous however in that they had gaps and full names of staff were not seen. It was strongly recommended that the home follow the Nursing and Midwifery Council guidance: Guidelines for records and record keeping. 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. Residents can be confident that they are offered a range of opportunities for personal development. Residents engage in a good level of activities which are appropriate to their needs and capabilities.Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The residents benefit from the appetising meals and balanced diet offered at the home. Evidence: Discussion with staff and residents confirmed that the level of activities were of a good quality and that they enjoyed a good level of stimulation through leisure and recreational activities. We had the opportunity to speak to several of the residents who expressed their opinion of the home and the activities they participated in and enjoyed. Other residents were observed participating and interacting with staff. Residents have been Care Homes for Older People Page 16 of 28 Evidence: enabled to and encouraged to participate in activities which they had an interest in. One resident was seen being given the opportunity to visit a Day Centre. Social care planning was not fully evidenced within the care planning process. This was identified elsewhere within the report. The manager stated that she will further identify and evidence social aspects within the residents care plans. It was confirmed that residents are enabled to maintain contact with relatives and friends where they wished to do so. One relative spoken with confirmed that the home was always welcoming and that he was happy with the standards of care and activities offered. The AQAA showed that residents are encouraged to use all aspects of their home according to their ability and wishes. Residents undertake a wide variety of activities. The AQAA evidenced that the home continues to contract an activities organiser who now attends once weekly. She offers craft sessions, quizzes, music therapy, bingo and reminiscing. Staff also offer activities in the afternoon e.g. board games, cards, quizzes and general conversation. There is a large screen to watch, with a DVD player in communal area. Local church continues to visit once monthly to offer group on individual services. Newspapers purchased daily. At Christmas time a organ player was invited and a local primary school to entertain. A theatre trip was arranged at the local theatre. One lady goes to go to bingo independently,one goes to Age Concern (a charity that provides support for older people) and some enjoy visits from their family. From observation, records viewed it was evident that residents were offered a choice of menus that meet their dietary needs and individual preferences. Meal times are flexible to suit the residents activities and schedules. Residents are able to choose where to eat, and also and have drinks and snacks for themselves. Residents on evidence seen have had been involved in planning and choosing what to eat where possible. This was additionally confirmed following discussion with one resident. However another resident wished to have more choices at mealtimes. 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. Residents can feel confident that their concerns and complaints are taken seriously. Residents are are protected from the risks of abuse. Evidence: A copy the complaints procedures was reviewed. The procedure included details of how to complain, timescales for response and information for referring a complaint to the service provider. However the complaints procedure is not readily available in different formats. Residents within the service have an understanding of how to make a complaint as their capacity and understanding allows. No complaints have been received from information contained within the AQAA. Systems are in place to ensure that these are dealt with appropriately. The homes Policy for the Protection of Residents and staff Whistle blowing procedure was discussed. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training has been provided for staff, evidence of this was seen within the staff files and training record. Further evidence and the AQAA showed the Complaints procedure is displayed at the main entrance to ensure it is made visible for everyone to see. Residents and families Care Homes for Older People Page 18 of 28 Evidence: are give a copy of the complaints procedure on admission and they are also verbally informed about the procedure by the manager. All staff trained in NVQ 2/3 have covered a module of adult abuse staff have also attended a study day on mental capacity as well as attending forums on vulnerable adults arranged by social services in the adult protection unit. Robust policies and procedures are in place as wel as having good practice documentation in place such as No Secrets and Kent and Medway Adult Protection procedures. The manager speaks to the residents daily when working as this gives the residents a opportunity to express any concerns or anxieties. Communication is effective and residents and famililes feel comfortable to raise and concerns or worries. A relative was spoken too who confirmed that they felt that their relative was protected and had no concerns about issues relating to her welfare. A key worker system is in place which enables to detect any concerns if any at an early stage. Legal rights are protected and when a resident who has lacked capacity professional advocacy service has been made available to the individual outside the home. The home promotes an open culture where Residents feel safe and supported to share any concerns in relation to their protection and safety. The manager stated that Criminal Record Bureau Checks (CRB) had been obtained for all staff . 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. Residents benefit from living in a good well maintained environment which provides a homely warm atmosphere. Residents are protected by the homes infection control procedures and policies Evidence: It was apparent that the individual and collective needs are being met in a comfortable environment. The standard of internal decoration and fixtures and fittings are well maintained and of a good quality. An environmental risk assessment has been carried out to maximise the safety of residents. The management and staff encourage residents to see the home as their own home. It provides a very well maintained, safe, comfortable, attractive home which has all the specialist equipment and adaptations needed to meet individual residents needs. Evidence seen and the AQAA showed that the layout of the home is suitable, accessible and well maintained for the residents to meet their needs. It is kept hygienically clean to a high standard. Bedrooms have been personalised to suit individual tastes. Residents have been given the opportunity to decorate if they wish to their personal choice. They are encouraged to bring personal belongings and furnishing to aid transition and ensure that they will be comfortable in the care home with their own Care Homes for Older People Page 20 of 28 Evidence: personal belongings. All rooms, en-suites, bathroom, lounge area have emergency call bell system. A ramp is available to use for a wheelchair. The communal bathroom has a bath hoist and toilet on the ground floor. The lounge and dining area furnished with comfortable chairs and foot stalls. It is equipped with a large screen television with DVD and freeview tv, a music system is also in place. The kitchen is clean and well maintained. The manager stated all food is properly stored within the guidelines SFBB (safer food for better businesses). Daily opening and closing checks are performed in the kitchen at the beginning and the end of the day to ensure good practise. Access to patio area leading to a mature garden is kept clean and tidy. Fire risks assessments have been carried out and all fire systems are checked regularly by contractors. Door guards are in place. Staff carry out weekly fire alarm testing and monthly emergency light checks. All staff have received fire training. Grab rails are installed around the home when needed. All rooms are provided with lockable storage space for personal items. The home spends money on the environment in the best possible way so that outcomes are improved as much as possible for the people using the service. All bedrooms promote high levels of privacy but do not presently have locks. All residents should they so wish have a key to their own room unless a person centred risk assessment indicates otherwise. The manager stated that she would canvass residents wishes, provide locks, risk assess and document. The home is very well lit, tidy and smells fresh. The premises are kept clean, hygienic throughout and systems are in place to control the spread of infection. The manager stated laundry facilities currently meet the needs of the residents living within the home. The laundry area is in the basement which consists of a industrial washing machine and tumble dryer. Contracted hygiene specialists remove yellow bags and sharp boxes from the premises. Policies, procedures and risk assessments are in place. All staff carry anti bacterial hand rubs and all residents rooms have been fitted with anti bacterial soaps to minimise the spread of infections. Water pipes have been fitted with thermostatic valves to ensure water is delivered to the residents at approximately 43 degrees. Staff have received training in infection control. 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. Residents care, social and emotional needs are promoted by the employment of caring staff in such numbers to support their needs who put the interests of the residents first. Residents can feel confident that they are supported by staff who have been employed by the home using good recruitment procedures. Evidence: From discussions with the manager, observations and reviewing the staff rotas sufficient staff were on duty at the time of inspection to meet the residents needs. Staff are receptive to residents needs and work together as a team. The manager stated staffing levels are always under review to ensure the needs of the residents are met. Risk assessments have been prepared both for the residents as individuals and the environment. The staff training records indicated planned and undertaken training in all the key areas. Core training in Infection control,Moving and Handling, Basic Life support, fire training, food hygiene, and Adult protection has been provided. The manager evidenced that individual and group staff training needs had been identified. Core courses are undertaken by staff to maintain current qualifications and for protection of Care Homes for Older People Page 22 of 28 Evidence: residents. Staff have achieved NVQ qualifications in Care to level 2 or above, thus meeting with the required standards. The manager confirmed that the home has a development programme for all new staff, which meets Sector Skills Councils workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users, and that all members of staff receive induction training to specification. The inspection of the recruitment files at the previous inspection evidenced that the required checks had been carried out and that the standard was met. Upon reviewing a sample of recruitment file the standard continues to be met. All required information was contained within the files and all checks of identity have been carried out. The manager stated all staff have CRB (Criminal Record bureau Checks). 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents needs are currently being met and can be confident that the home is managed appropriately and that the quality assurance of the service is monitored. However more formal quality assurance visits of the provider were not evidenced. Residents can feel confident that their health and safety safety is protected. Evidence: The manager is actively involved in the day-to-day management of the home and works with staff and residents. She has many years of experience caring for others and is a Registered Nurse. Outcomes for the quality of care are good. Residents expressed a great deal of satisfaction of the care provided and the staff are very supported of the manager and have a positive ethos. There is strong evidence that the ethos of the Home is open and transparent. The views of both residents and staff are listened to, and valued. Care Homes for Older People Page 24 of 28 Evidence: Quality assurance was discussed and the views and opinions of many of the residents and stakeholders sought. The residents spoken with confirmed a great deal of satisfaction living within the home and felt confident that their views and opinions were valued by both staff and management. The home operates a key worker system to identify an individual staff member to directly to work with a service user on a one to one basis. An appointed person of the registered provider of the home does not regularly visit the home and complete what is known as a Regulation 26 visit. This requires the provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. The manager confirmed that the home has a quality assurance process in place that measures the quality of care given and that the views of residents are included however this is not formalised as described above. The manager stated that this shortfall would be addressed. No statutory requirment has been made at this time as the Commission is confident that this shortfall will be addressed. Evidence of health and safety safety checks were inspected. Evidence showed that required checks had been carried out and the manager stated that they were up to date. The fire escapes were reviewed and the manager was requested to risk assess and seek advice from the Fire Officer to ensure access to the fire exits is safe. 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 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 27 of 28 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk 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 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!