Care Home: Philbeach Nursing Home

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What the care home does well Philbeach Nursing Home is registered to provide accommodation and care for up to 61 older people. The home is surrounded by attractive gardens and provides a good range of communal and individual space for the people who use the service. There are well established pre-admission assessment processes and the needs of prospective service users are assessed prior to admission. Up to date information about the service is provided within the service user guide. The home provides a good programme of activities ensuring that residents have the option of participating in a range of groups and events. Individual service user files have been well developed and address all assessed needs and perceived risks. The plans include clear guidance to enable staff to consistently meet needs. Residents told us that they are able to make choices and decisions about how they wish to spend their time and that staff are respectful and supportive. Medication issues were seen to be well managed with records kept up to date, policies and procedures in place and staff administering medication having received appropriate training. Service users were very positive about the quality of the food in the home and stated that there are choices at each mealtime. The cook told us that he speaks to residents to gain feedback about the food and that he is ale to purchase good quality produce. There is a complaints process in place and evidence was available to show that the home manages complaints appropriately. The home is well staffed and it was reported that numbers of staff are altered dependent on the needs of the service users. All records pertaining to health and safety were up to date and well maintained and the organisation has developed a quality monitoring programme that includes feedback from stakeholders, audits and monthly management reports. What has improved since the last inspection? A new, experienced manager has been appointed who has developed improved systems in a number of areas. She has introduced a system of champions, where staff are able to identify areas of interest and promote quality in that area. The care planning process has been improved ensuring that the needs of the service users are met and guidance is clear and unambiguous. A range of assessments, updated on a monthly basis, have been introduced covering key topics such as pressure area care and dependency amongst other things. The supervision system for staff has been improved and there is evidence available showing that staff receive regular formal support from a senior member of staff. Staff stated that they feel supported in their roles. Areas of the home environment have been improved. The ground floor communal space and bedrooms have been almost completely refurbished and redecorated and there is a maintenance programme in place. What the care home could do better: 2 requirements and 4 recommendations have been made under the Care Standards Act 2000. One requirement relates to the on-going refurbishment of the home. The upper floors of the service have begun to be refurbished, but this is in the early stages. Other areas for improvment were also identified and are detailed in the body of the report. The organisation needs to submit an action plan detailing timescales for work to be completed in order that this can be monitored throughout future inspections. The second requirement relates to infection control measures in the home. During the site visit it was noted that a number of infection control processes had not been followed and some equipment not maintained. These were discussed with the manager and actions need to be taken to address these shortfalls. It is recommended that the interests, hobbies and preferences of service users are documented and accessible to all staff. Additionally, the organisation needs to continue to provide training for all staff covering all mandatory and service specific topics. Recruitment records are generally well managed, but where pre-employment information has not been received the home should ensure that there is clear evidence of actions taken to address these. There is a relatively new manager in post, who now needs to be put forward for registration with the Commission. It was also noted during the site visit that there were times when staff could have improved the level of communication with service users, especially when assisting with transfers and during mealtimes. This issue was discussed with the manager who agreed to monitor this aspect of care. Key inspection report Care homes for older people Name: Address: Philbeach Nursing Home Tanners Hill Hythe Kent CT21 5UE     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: Joseph Harris     Date: 1 5 1 0 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 27 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 27 Information about the care home Name of care home: Address: Philbeach Nursing Home Tanners Hill Hythe Kent CT21 5UE 01303262421 01303238785 moiraedmondson@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Philbeach Care Centre Ltd care home 61 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 61 The registered person may provide the following category of service: Care home with nursing (N) to service users of the following gender: Either whose primary care needs on admission t other home are within the following category: Old age, not falling within any other category (OP) Date of last inspection Brief description of the care home Philbeach Care Centre is a large detached three storey building set in 9 acres of attractive grounds. The home has a terrace with good views over well-maintained gardens. It is situated on the outskirts of Hythe close to shops and other amenities. A refurbishing programme of decorating and installing en-suite facilities in bedrooms, in the long term, is in progress. The home provides residential and nursing care. The Company owns other care homes, the bungalows in the grounds and two Domiciliary Care Agencies. Weekly fees and additional charges are available from the manager on request and summarised within the service user guide. Care Homes for Older People Page 4 of 27 Over 65 61 0 1 6 1 0 2 0 0 8 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: This key unannounced inspection process culminated in a site visit to the service on the October 2009. The site visit was carried out by Regulatory Inspectors, Joseph Harris and Anne Butts. Prior to the site visit a range of records and information received was examined and reviewed including the Annual Quality Assurance Assessment (AQAA) completed by the service providing a summary of things that have changed and improved over the past 12 months. This document also includes issues that the home have identified and how they plan to develop them and additional statistical information. Other information we considered included notifications received by the service, past inspection reports and the results of any other site visits, information received from other people and any concerns, complaints or allegations received. During the site visit a tour of the premises was undertaken and discussions were held with service users, visitors, staff, the manager and a senior manager from the organisation. Care Homes for Older People Page 5 of 27 A range of records were examined in the service including files relating to service users and staff. We also looked at documents and information regarding health and safety, medication and complaints amongst other things. The site visit commenced at 10:00 hours and lasted for approximately 6 hours. Care Homes for Older People Page 6 of 27 What the care home does well: What has improved since the last inspection? What they could do better: 2 requirements and 4 recommendations have been made under the Care Standards Act 2000. One requirement relates to the on-going refurbishment of the home. The upper floors of the service have begun to be refurbished, but this is in the early stages. Other areas Care Homes for Older People Page 7 of 27 for improvment were also identified and are detailed in the body of the report. The organisation needs to submit an action plan detailing timescales for work to be completed in order that this can be monitored throughout future inspections. The second requirement relates to infection control measures in the home. During the site visit it was noted that a number of infection control processes had not been followed and some equipment not maintained. These were discussed with the manager and actions need to be taken to address these shortfalls. It is recommended that the interests, hobbies and preferences of service users are documented and accessible to all staff. Additionally, the organisation needs to continue to provide training for all staff covering all mandatory and service specific topics. Recruitment records are generally well managed, but where pre-employment information has not been received the home should ensure that there is clear evidence of actions taken to address these. There is a relatively new manager in post, who now needs to be put forward for registration with the Commission. It was also noted during the site visit that there were times when staff could have improved the level of communication with service users, especially when assisting with transfers and during mealtimes. This issue was discussed with the manager who agreed to monitor this aspect of care. 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 8 of 27 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 9 of 27 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. Prospective service users can make an informed choice about the home and their needs are suitably assessed prior to moving in. Evidence: A statement of purpose and service users guide are in place and show evidence of recent review. Both documents contain sufficient information about the service in a presentable format covering all key topics. There is also a brochure in a glossy format to supplement these. A copy of the guide and brochure are kept in all bedrooms and given to all prospective service users/representatives. One service user said, I have only recently moved in. They have been so good to me and made me feel very welcome. Im extremely happy here. They also confirmed that they had received a service user guide and had been offered visits to the home before moving in. Care Homes for Older People Page 10 of 27 Evidence: The home has an established admissions process, which was discussed with the deputy manager, who undertakes assessments. Examples of recently completed preadmission assessments were examined that contained a good level of information covering all key areas of need. Information is received from care managers and/or service users representatives. Initial assessments are developed from a range of information and are used to inform the plans of care. Service users, following an initial assessment in their current accommodation, are invited to visit the home, meeting staff and other residents. Following admission a review is held after 6 weeks to ensure all aspects of care and support are being met. The home does accept service users requiring short-term or respite care where vacancies occur. The service does not provide dedicated intermediate care facilities. The admission process is followed for people on respite care. Care Homes for Older People Page 11 of 27 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. The health and personal care needs of service users are met. Evidence: Three individual service user plans were examined all of which contained good levels of information regarding the needs of each person. There is a comprehensive range of assessments completed and updated on a monthly basis. The assessments cover issues such as pressure area care, dependency, moving and handling and nutrition amongst others. Plans of care are developed in relation to these assessments and updated accordingly. The home uses a model of nursing care format in planning care covering the holistic needs of each individual. There is a clear focus on nursing needs, but the plans also provide good guidance covering mental health and communication needs. The plans are written in a way that staff have the information to be able to deliver consistent care. Issues relating to risk management are detailed within the plans of care. There is evidence of monthly review and addressing changing needs. Healthcare needs are suitably addressed and there is evidence that the home works well with healthcare professionals. A Registered Nurse is on duty within the home at Care Homes for Older People Page 12 of 27 Evidence: all times. Healthcare records examined demonstrated that issues of concern are referred appropriately and outcomes recorded. The manager stated that good support is received from community health and social care teams. One visiting professional said, I havent been here for some time, but its clear things have improved. All of the service users are registered with local GPs and complimentary healthcare needs such as podiatry and dentistry are met. Three of the Registered Nurses take joint responsibility for medication issues within the home including the auditing of records, stock and ordering medication. Medication administration records were kept up to date and any changes were countersigned. Records are retained of any returned or destroyed medication. The use and stock of controlled drugs are monitored and there are suitable storage facilities for this purpose. Medication was seen to be stored in an orderly manner and clearly labelled. Medication is only administered by Registered Nurses who have received appropriate training in this regard. There is sufficient storage in the clinical room for additional topical medication and dressings. Staff were observed to interact in a positive and respectful manner with service users and visitors. Residents confirmed that staff respect their privacy and dignity and develop good relationships. One person said, All the staff are lovely, I couldnt praise them highly enough. Care Homes for Older People Page 13 of 27 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 user have a lifestyle that suits their needs. Evidence: Service users benefit from an active and varied programme of activities. The home employs a full-time activities co-ordinator. Activity plans are in place for each resident and cover group and individual activities. The co-ordinator has developed a system to monitor the level of participation in all activities, thereby ensuring the all residents have regular input according to needs and wishes. Activities are advertised and residents are encouraged to put forward new ideas. A number of outside entertainers visit to do music and drama afternoons. There are also visiting therapists who do exercise and music therapy groups. The exercise group was observed and service users participated well and said that they enjoyed it. The acting activities co-ordinator said that she has a good and flexible activity budget. It is recommended that the home develops a system of recording interests and preferences that is widely available to all staff. Refer to recommendation 1. Visitors are welcomed into the home at all reasonable times and there is adequate space for people to meet in private should they wish to do so. One visitor said, were always made to feel so welcome, its lovely. Care Homes for Older People Page 14 of 27 Evidence: Residents confirmed that they are able to choose how they organise and spend their time in all aspects of their lives. This includes when they choose to get up or go to bed, choice of meals and activities amongst other things. Residents meetings are held on a regular basis and the service users are encouraged to air their views. The home employs a full-time cook, in discussion he stated Im passionate about my job. Its about putting the residents first, Ill make sure people have what they want. He said that he receives a good budget for food and all of his equipment is in good working order. It was noted that the kitchen may benefit from a deep clean, however one of the senior managers stated that this has already been arranged. Service users were very positive about the food, one person said, the food is very nice, i dont like to eat my greens, but i always get a choice, another person said I like my boiled egg in the morning, the meals are always nice. A mealtime service was observed, people were offered choices and staff were unhurried and relaxed. It was noted that the dining room was very quiet and more effort could be made to make it a more social affair. People can choose to eat in their rooms and staff are available to give assistance where required. Care Homes for Older People Page 15 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The views of service users are listened to and they are protected from abuse. Evidence: There is a complaints process in place that is included in the service user guide and displayed in the home. The manager stated that the home take their views of service users and relatives very seriously and try to resolve any issues as quickly and easily as possible. A record of complaints is retained and there was evidence that any concerns or complaints received have been dealt with in an appropriate manner. Any actions arising from complaints are recorded. 10 complaints have been received and addressed in the last 12 months. People we spoke to told us that they would feel able to raise any concerns and complaints and that their views would be taken seriously. Service users said that they would feel comfortable raising concerns with any of the staff. One person said, Ive got no complaints, but I would have no problem talking to someone if I did. Information received by us and the homes AQAA show that there have been 4 safeguarding vulnerable adult alerts over the past 12 months raised in connection with the service. Three of these have now been resolved and any actions identified from investigations implemented. One alert remains outstanding and is subject to investigation. The manager stated her intention to co-operate fully with the Safeguarding Vulnerable Adults team. It should also be noted that a new management Care Homes for Older People Page 16 of 27 Evidence: team has been appointed following a number of these referrals. Staff have received updated training in relation to adult protection issues and training has also been provided covering the Mental Capacity Act and the Deprivation of Liberty Safeguards. Care Homes for Older People Page 17 of 27 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 adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises are conducive for the needs of the service users, but improvements need to be made. The service should review infection control processes. Evidence: A tour of the premises was undertaken and it is evident that improvements have been on-going over the past 12 months, although it was acknowledged that there remains work still to be completed. A refurbishment and redecoration programme has been implemented and one of the senior managers stated the organisations intention to remain within set timescales. The home is located on the outskirts of Hythe with a bus route situated directly outside the property. The house is set back from the road and has a large car park with attractive and substantial grounds surrounding the property. The ground floor of the home has been almost completely redecorated and refurbished. There is a large open plan reception area past which are bedrooms, communal areas and office space. The upper floor has yet to be redecorated, but work had been commenced and one of the bathrooms was undergoing refurbishment during the visit. The home benefits from a good range of communal space, with good quality furniture. People are able to choose between the main lounge or quieter rooms. There is a large dining room that is attrractively presented and spacious. Care Homes for Older People Page 18 of 27 Evidence: A number of bedrooms were viewed all of which were seen to provide a comfortable space with sufficient furniture and facilities. Some of the bedrooms have en-suite facilities. Residents are able to personalise their rooms according to taste and are encouraged to bring in furniture and ornaments from home. There remains work to be done and improvements to be made notably, the small patio area accessible to the service users needs to be secure, the fencing currently in place is of a temporary nature. The kitchen and laundry areas would benefit from a deep clean and some maintenance issues being addressed. It was stated that this work is planned, but has not yet been booked for completion. A communal lounge on the first floor, which is currently not in use, has trailing wires from electrical appliances that need to be made safe before the room can be used. Many of the Anti-bacterial gel dispensers were empty on the day of inspection. A clinical waste disposal bin was not working correctly and two cleaning cupboards had been left unlocked. Refer to requirement 2. The senior manager stated that there is an action plan for environmental improvements that will be updated. A copy of this action plan with timescales for completion needs to be submitted to the Commission to ensure that progress can be monitored in this area. Refer to requirement 1. Care Homes for Older People Page 19 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient numbers of well trained and competent staff. Recruitment practices are maintained. Evidence: Staffing rotas were examined and demonstrated that there are sufficient numbers of staff on duty at all times. In addition to team of ancillary staff the home operates with 2 Registered Nurses and 9 care staff in the mornings; 1 Registered Nurse and 8 care staff in the afternoon/evening and 1 Registered Nurse and 3 care staff awake at night. Staff members spoken to confirmed that there are enough staff on duty and that agency nurses can be used if there is a shortage. The manager stated that the staffing compliment is altered dependent on the needs of the service users. The AQAA submitted by the service states that 19 members of the care team have achieved at least an NVQ level 2, which represents over 50 of the staff team. This was supported by the information in the staff training matrix. Staff were observed to be kind and considerate in their manner and were unhurried and relaxed in their duties. It was noted that some staff did not interact with service users when assisting with transfers and during the lunch service. These issues were discussed with the manager, who agreed to monitor this and address as required. The manager has introduced a system of champions covering topics such as dignity, equality and diversity and health and safety amongst many others. This system promotes individual responsibility and improved standards. Care Homes for Older People Page 20 of 27 Evidence: Six staff personnel files were examined. Each file contains a pre-employment checklist and all required checks have been completed. In two cases only one written references were on file and although efforts have been made to send out reminders records relating to this need to be more robust. Refer to recommendation 2. All new staff work through an induction programme which includes a 1 week intensive training course covering all mandatory topics, the Common Induction Standards and an in-house induction process. The staff training matrix and certificated evidence demonstrated that the majority of staff have had up to date training and where refreshers are required training has been booked and arranged. Nursing staff stated that they receive training suitable for their roles and professional competency. Some service specific training courses are provided including dementia awareness and diabetes training, but further courses could be considered. Refer to recommendation 3. Care Homes for Older People Page 21 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well managed in the best interests of service users. Health and safety issues are addressed. Evidence: The manager has been in post for approximately 1 year. She has not yet applied for registration with the Commission. Refer to recommendation 4. The manager has many years of experience in the field of care and has achieved the required qualifications for her role. She demonstrated a good awareness of the issues of the home and has introduced good systems for promoting the quality of care and staff responsibility. Quality assurance processes have been developed and these include surveys for service users, relatives, professionals and staff. The results of these surveys are collated in an annual report. Monthly monitoring visits are carried out by a senior manager and action plans developed from this. There are also a number of in-house audits completed on a monthly basis covering key topics. The home does not act as an appointee for any service users, financial issues are managed by people independent of the organisation. The home provides a safe Care Homes for Older People Page 22 of 27 Evidence: keeping service and records are retained of all incoming and outgoing transaction. There is evidence that staff are supported through a system of supervision. Records are kept on staff files of supervision sessions, which occur at least every 2 months. Staff stated that they feel supported in their roles. All health and safety records examined were up to date. This included fire safety records, service certificates such as gas, electrical wiring and specialist equipment. The majority of staff have received the required training and safe systems of working are promoted through policies and procedures. Care Homes for Older People Page 23 of 27 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 24 of 27 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 19 23 (2) The registered person 23/11/2009 shall having regard to the number and needs of service users ensure that b) the premises to be used as the care home are of sound construction and kept in a good state of repair internally and externally; d) all parts of the care home are kept reasonably decorated. o) external grounds which are suitable for, and safe for use by, service users are provided and appropriately maintained. To provide the Commission with an updated action plan addressing environmental improvements including timescales for completion. 2 26 13 (3) The registered person shall make suitable arrangements to prevent infection, toxic conditions 23/11/2009 Care Homes for Older People Page 25 of 27 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 and the spread of infection in the care home. To ensure that all necessary measures are taken and equipment in place to minimise the spread of infection. 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 2 3 4 12 29 30 31 To develop a system for recording hobbies, interests and preferences. To ensure that all records relating to recruitment issues are up to date. To identify further topics for training specific to the service and service users needs. The manager needs to apply for registration with the Commission. Care Homes for Older People Page 26 of 27 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 27 of 27 - 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. 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