Care Home: Regent

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What the care home does well The home is purpose built and provides an excellent standard of accommodation, which is clean, tidy and well maintained. This means that residents live in a safe and well maintained environment. The home provides good information to prospective residents to help them make choices about living in the home. A good choice of meals is always available with further alternatives if desired. Personal and health care is provided as needed by each resident. The residents` were satisfied with their healthcare treatment and felt that they were treated with dignity and respect by the staff. Staff are caring and respectful towards people living at Regent and understand the importance of treating people as individuals. We saw and heard examples of sensitive care practice during the inspection and received positive comments from residents and relatives. There is a wide range of in-house and community activities for those who wish to participate. What has improved since the last inspection? Since the last inspection the provider has redecorated and re-carpeted large parts of the home. Purchased equipment including a third hoist and additional tumble dryer. Introduced virtual home`s tour on the Internet for prospective residents and their representatives. Staff training in dementia care, palliative care, pressure ulcer management and NVQ training in care has taken place. This ensures residents are cared for by staff who are qualified to meet their needs. What the care home could do better: Explore the possibility of installing automatic front doors to assist those residents with walking aids. Focus on spiritual needs, within the planning of care, which may not be religious. This would provide for those residents who may not follow a specific religion but have spiritual care needs. Produced the menu in different formats for residents with specific needs for example picture menus. CARE HOMES FOR OLDER PEOPLE Regent School Road St Johns Worcester Worcestershire WR2 4HF Lead Inspector Gillian Goldfinch Unannounced Inspection 27th June 2008 15:00 X10015.doc Version 1.40 Page 1 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 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Regent Address School Road St Johns Worcester Worcestershire WR2 4HF 01905 337100 01905 420278 regent@heart-of-england.co.uk www.heart-of-england.co.uk Heart of England Housing and Care Limited Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Sandra Ann Dixon Care Home 60 Category(ies) of Dementia - over 65 years of age (60), Old age, registration, with number not falling within any other category (60), of places Physical disability over 65 years of age (60) Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home may provide care and accommodation for one named person over the age of 65 years with learning disability needs. The home may provide care and accommodation for two named persons under the age of sixty-five years, one who has a learning disability and who has a sensory impairment. 14th November 2006 Date of last inspection Brief Description of the Service: Regent is a purpose built home situated in a residential area of St Johns on the outskirts of the city of Worcester. It is well placed for access to local amenities and transport. The two-storey building has sixty single bedrooms, all with en-suite facilities. In addition there are communal lounges, dining rooms, toilets and bathrooms on each floor. Shaft lifts facilitate mobility between floors and there is ground floor access to a pleasant enclosed garden. The home is owned by Heart of England Housing and Care Ltd and managed by Mrs Sandra Ann Dixon. A service is offered to a maximum of sixty people of either sex over the age of sixty-five years who have needs associated with old age including physical disabilities and dementia illnesses. The conditions of registration listed above also apply. In the service Users Guide given to us on the day of the inspection the fees quoted were £455.00 - £485.00 per week for a single room. Up to date information about the fees should be requested from the service. Additional charges were made for hairdressing, chiropody, newspapers and periodicals, Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means the people who use this service experience excellent outcomes. This was an unannounced inspection of the home to look at how the home is performing in respect of the core national minimum standards (the report says which these standards are). We call this type of inspection a key inspection. The service had previously completed an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment and a dataset that each registered provider has to complete each year and send to us within agreed timescales. The document tells us about how providers of services are meeting outcomes for people who use the service and is an opportunity for them to share with us what aspects of the service they believe they are doing well. Some of the manager’s comments have been included within this inspection report. We also received completed survey forms from ten people who use the service and nine of their relatives. The information from these sources helps us understand how well the home is meeting the needs of the people using the service. During the inspection, we spoke with the care services manager who is responsible for the assessment and provision of care, and the supervision and development of staff. We also spoke with some residents, some staff and three visiting relatives. There was a tour of parts of the building and time was spent observing what the arrangements were at lunchtime and the administration of medication. Throughout the inspection, there were opportunities to observe and overhear staff contacts with people who live in the home. Documentation was checked, including the care records of people who live at Regent and some staff files. Copies of policies and procedures were made available. What the service does well: The home is purpose built and provides an excellent standard of accommodation, which is clean, tidy and well maintained. This means that residents live in a safe and well maintained environment. The home provides good information to prospective residents to help them make choices about living in the home. Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 6 A good choice of meals is always available with further alternatives if desired. Personal and health care is provided as needed by each resident. The residents’ were satisfied with their healthcare treatment and felt that they were treated with dignity and respect by the staff. Staff are caring and respectful towards people living at Regent and understand the importance of treating people as individuals. We saw and heard examples of sensitive care practice during the inspection and received positive comments from residents and relatives. There is a wide range of in-house and community activities for those who wish to participate. What has improved since the last inspection? What they could do better: Explore the possibility of installing automatic front doors to assist those residents with walking aids. Focus on spiritual needs, within the planning of care, which may not be religious. This would provide for those residents who may not follow a specific religion but have spiritual care needs. Produced the menu in different formats for residents with specific needs for example picture menus. Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service provides written information to help people decide if Regent is the best place for them or their relative to live. Detailed information is obtained during the assessment of prospective residents and relevant people are asked to provide information; this means that staff have the information they need to decide if they can provide the right care for people. EVIDENCE: People thinking about Regent for themselves or a relative are given written information about the home. This consists of a document called “Your Guide to Our Services” the Service User Guide; this document describes aspects of the service provided, and explains that the home provides accommodation for 60 older people including those with physical disabilities and/or with dementia related illnesses. The information tells people about life at Regent and the service they can expect. It describes the accommodation and the Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 10 qualifications and experience of the senior managers within the organisation, the manager of the home and staff. It also explains how to make a complaint. Copies of this document are provided for each individual and are also located throughout the home; this allows residents can look at them whenever they wish. All this information is available in different formats, for example on tape for someone with poor eye sight, on request. The relative of a resident told us he was happy with the way in which his mother’s admission to the home had taken place; with the information provided by the home and the way in which his mother’s needs had been assessed before she moved in. Five residents who spoke to us confirmed they had been provided with information about the home before their admission and that this information was made available for them to keep Staff from the home obtain information about people before they offer someone a place at Regent. When someone is being assisted with funding by a local authority, this includes obtaining a copy of assessments carried out by the authority’s social care staff. This helps Regent staff check that they are likely to be able to meet a person’s needs. Copies of four pre-admission assessments were seen. These contained comprehensive and detailed information on the care needs of each prospective resident. Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. All residents had a plan of care based on their individual needs. This means that staff had the necessary information to assist residents in meeting their health and social care needs. Residents felt they were treated with dignity and respect and that their privacy was maintained. The home had policies and procedures in place for the safekeeping and administration of medication. EVIDENCE: The home has a dedicated member of the management team responsible for the assessment and provision of care. The plans of care for six residents were inspected. These were comprehensive, containing up to date information on the care needs of each resident and clear instruction to staff on how these were to be met. Risk assessments had been undertaken where concerns had been identified. There was evidence that care records were being reviewed and updated on a monthly basis. Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 12 Daily records and information relating to visits by health care professionals were well kept and detailed. The manager wrote on the pre inspection AQAA that the home had an excellent rapport and positive relationship with all visiting health care professionals including G.P’s, community nurses, continence advisor, visiting chiropodist and psychiatric nurses. Resident’s told us they were able to access health care services as they wished and able to see their G.P and other visiting professionals in the privacy of their own bedroom. Residents told us they were aware that records about their care needs were held by the home. Some records seen had been signed by individual residents while others had signed to say they did not wish to be involved with written documentation about their care needs. Staff at the home work hard to maintain and promote the healthcare needs of residents. The manager wrote on the pre-inspection AQAA that improvements had been made to the way in which care needs were documented to make plans of care more person centred and to involve residents and their representatives more in the planning of their care. The manager stated other improvements made since the last inspection as: • • • Recruitment of a physical exercise co-ordinator Accessing an aroma therapist for individual residents Management and staff training in dementia care Residents’ questionnaire responses indicated that they received the care and support they needed and the staff listened and acted on what they said most of the time. The home had a policy and procedure for the administration of medication, which was kept under review and updated when necessary. We observed the administration of medication at teatime. A member of care staff undertook this. We observed medication being appropriately administered. Appropriate records were signed at the point at which the medication was given. A sample of medication records were inspected including the records and stock of controlled drugs held in the home. These were found to be appropriately kept and stored securely according to requirements. Staff involved in the administration of medication had undertaken accredited training in the control and administration of medicines. We saw staff being gentle, caring and respectful towards residents. Those residents who spoke to us stated they were treated with dignity and respect. All bedroom doors were fitted with approved locks and residents had access to Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 13 their door keys and the keys to lockable storage. Their mail was delivered unopened and private telephone calls could be made and received. Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home promoted the residents’ quality of life by seeking their views, offering choice and encouraging them to remain as independent as possible. Residents were able to express their views and be involved in decisions that concern the home. Residents can participate in a range of in-house and community activities if they wish. Residents were provided with a choice of good quality meals, which they enjoy. EVIDENCE: Residents’ preferences about how they spend their leisure and recreational time are detailed in their care records and are regularly reviewed. The home employs two activity co-ordinators who help organise the activities requested by those who live at the home. In addition the home has a resident representative who speaks to other residents on a daily basis regarding all aspects of life at the home including social and leisure activity. We spent time talking to the resident representative about their role and were told that they take time each day to feedback to the manager of the home comments, complaints and any recommendations made by other residents. The resident Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 15 representative is also responsible for the cinema in the home, which offers matinee and evening viewings of films, requested by other residents. This service was much appreciated by residents who spoke to us. The home is also involved in the ‘Having Your Say’ project, which provides a forum for those who live at the home to voice their opinion and make recommendations and suggestions as to how the home operates. A separate representative from ‘Having You Say’ visits the home to speak to the residents. The home holds regular resident meetings and minutes are kept of these. Planned activities were advertised on the notice boards on each floor. These were comprehensive and varied. A record of activities was kept. These include: • • • • • • • • • • Theatre trips One to one activities with individual residents Visits to restaurants to eat out Themed meals within the home Exercise classes with qualified therapist Aromatherapy session with qualified therapist Regular church services Current affairs group which meets in the home Mobile library Quizzes Resident questionnaires showed satisfaction with the social and recreational activity provided by the home. On the day of the inspection staff and residents were busy preparing for the annual fete which was to be held the following day. Visitors to the home are welcome and encouraged. The residents with whom discussions were held stated their relatives and friends were always made welcome and offered a drink. The residents also confirmed that they were able to see their relatives in private. The homes Service User Guide stated; “It is important for residents to have contact with their families and friends and we encourage them to use their personal rooms for such events. The home can provide larger private facilities if requested”. The hotel services manager, a member of the home’s management team, is responsible for the catering service. Dietary needs are assessed on admission to the home and this information is passed to the catering staff and hotel services manager. The hotel services manager meets with each resident soon after their admission to discuss dietary needs. Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 16 The homes Service User Guide stated; “Meals are freshly prepared and cooked each day by our catering staff and these provide a well balanced and nutritious diet”. A choice of meal is available each day and a vegetarian option is routinely provided. Menus are reviewed every three months and residents are asked to complete a questionnaire about their satisfaction and dietary preferences for consideration in the planning the new menus. Meals can be served in the small dining areas on each floor or in the residents’ own room if preferred. Light snacks and fresh fruit were available in each of the small kitchenettes and are available at any time of day or night. One resident told us: “I like a cup of tea at night and can always have one if I want”. Another stated; “The food here is excellent, the staff know what I like and don’t like and there is always plenty of it. You couldn’t fault the food”. The manager and staff supported each resident in their right to exercise personal autonomy and choice. The home’s Service Users’ Guide contained information about the local advocacy service. A poster with similar details was also displayed on the notice board. There was evidence that residents were able to bring personal possessions with them on admission to the home. The Service Users’ Guide contained information about the residents right of access to records held about them by the home. The residents with whom discussions were held confirmed that they were able to make choices about their daily routines and matters affecting their care e.g. the clothes they wore, the food provided, where they ate their meals and the time they got up and went to bed. Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 17 Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. There is good access to the complaint procedure and people confidently use it and receive an acceptable response. Staff are appropriately recruited and trained to protect the residents in the home. EVIDENCE: The home had a clear complaints procedure, which was included in the service users’ guide. A copy of the complaint’s procedure was also displayed on the notice boards on each floor of the building.. Residents with whom discussions were held felt confident about making a complaint. They also felt that any complaint made would be dealt with appropriately. They all felt that manager was approachable. The home’s Service User Guide states: “Our commitment to residents and relatives is to respond to any complaints or queries about the care and services that we provide in a manner that is prompt, courteous and sympathetic.” The complaint’s record was seen and showed that appropriate action had been taken to address any concerns raised. The record seen for the previous three Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 19 months showed an analysis of concerns, complaints and complements. There had been one complaint made by a resident about care. There was evidence to show that this matter had been appropriately dealt with and resolved. The record showed there had been fourteen complements about the care provided and nine complements about the catering service. Access to independent advocacy service is available to residents if they wish to use it. Details of how to contact senior managers within Heart of England Housing and Care Limited and The Commission for Social Care Inspection were contained in the complaints procedure and the Service Users Guide. The home had a policy and procedure for the protection of vulnerable adults from abuse. This had been inspected at the previous inspection and found to be satisfactory. The policy was kept under regular review. All staff except two had received training in the protection of vulnerable adults from abuse. Staff who spoke to us were clear about what constitutes abuse and what action they would take in the event of discovering an incident of abuse. The care services manager confirmed that no incidents of alleged or suspected abuse had occurred or had been reported or had otherwise come to her attention since the previous inspection. Staff were able to demonstrate they had been appropriately recruited and trained to support and protect the vulnerable people in the home. Their records confirmed this. There had been no reason to refer any member of staff for consideration for inclusion on the protection of vulnerable adults register. The home had a copy of the Department of Health guidance ‘No Secrets’. The home’s ‘whistle blowing’ policy and the policy on the service users’ money and financial affairs were satisfactory. Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable clean home that meets their needs. They have access to the garden for fresh air, exercise and recreation. The risks of cross infection are reduced as much as possible by the equipment and systems in place. EVIDENCE: The home was purpose built and has been maintained to a high standard. It was observed to be clean, hygienic and free from offensive odours. There was a programme of regular maintenance for all equipment and an annual management plan to identify any necessary renewal of the fabric, furnishings and decoration of the premises. Weekly and monthly checks were in place as required for the testing of equipment such as call bells and the fire Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 21 safety system. There was a Fire Safety Risk Assessment in place for the home. The building meets the requirements of the local fire service. The management team undertakes a monthly health and safety walkabout inspection of the home. All necessary aids and adaptations were available to meet the assessed needs of the resident group. All areas of the home were accessible. A passenger lift accesses all floors. The garden areas had been further developed since the last inspection. The garden is accessible, safe and secure. It is well maintained with paths leading to areas of seating providing a quiet and peaceful place for residents to walk or different shrubs and flowers. Those residents who spoke to us were happy with the environment they live in and the high standard of accommodation. All bedrooms are single and all have en-suite facilities, computer and telephone sockets. Residents stated they felt safe and secure in the home. Questionnaire responses indicated that the residents and their relatives appreciated the high standards of the environment. One person said that the home was ‘always clean and tidy and was well decorated”. There was an appropriately located and fully equipped laundry facility. An additional tumble dryer had been purchased since the last inspection. Policies and procedures were in place for the control and spread of infection. Personal protective equipment, liquid soap, disposable hand towels and waste disposal systems were available to reduce the risks of cross infection and staff and records confirmed that training had been undertaken. . Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff were experienced, trained and employed in sufficient numbers to meet the needs of the residents. Residents were protected by the homes thorough recruitment procedures. EVIDENCE: A copy of the staff rota was made available for inspection. . The staff rota showed that the home was adequately staffed during the day and at night, with additional staff on duty at peak times of activity during the day. There was a separate team of catering staff and separate cleaning staff. The provider and manager are committed to providing appropriate training for the staff group. Comprehensive records were kept of training provided and of training planned for the future. Staff had received training in the core areas of health and safety. Many of the staff were working towards or had achieved an NVQ qualification in care at level 2 or 3. A training matrix was available which showed staff had completed induction and core training and showed when training updates were due. Staff who spoke to us stated they had received appropriate training this was confirmed by their training records. A selection of staff files were inspected and all were found to contain the required information, showing that thorough recruitment procedures were in Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 23 place for the appointment of new staff. These included, written application forms, evidence that relevant police checks had been undertaken, two written references, contract and statement of terms and conditions of employment and job descriptions. These procedures ensure good recruitment and the safety of those who live at the home. Recently appointed staff spoke to us of their recruitment process, which was thorough and robust. Residents we talked to and questionnaires received made positive comments about staff. One resident stated, “The staff are kind and caring, nothing is too much trouble, they work hard”. Another resident said, “They clean my room well, I have everything I need here, I am well looked after, the staff are gems”. One relative commented, “The staff know their job, they work hard and give good care and attention to my Dad. We are happy with the home”. Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is excellent, This judgement has been made using available evidence including a visit to this service. The home is well managed in the interests of the residents. Health and safety systems protect those in the home. The systems in use are regularly monitored in order that quality can be assessed and the service can develop. Residents’ personal monies are well managed in their best interests. EVIDENCE: The management structure in the home ensured that resident’s needs; health, safety and welfare were maintained and protected. There is a home manger Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 25 and management team consisting of the care services manager and hotel services manager who are supported by a team clerk. The manager was experienced and competent to manage the home and had several years experience in the care industry. She had successfully completed the Registered Managers Award, as had the care services manager. Feedback from relatives to questionnaires and the in-house quality assurance process indicated that people considered they were kept well informed by the manager. One relative stated that communication between her and the home was good. The staff described the management team as supportive and knowledgeable. One person said that the support from the management team was ‘excellent’. Another person said that there was a ‘strong team’, which was appreciated. All staff received regular supervision/support sessions and personal development reviews were held, these were all recorded. Regular staff meetings were held. The home had a quality assurance system and the service providers visited the home frequently; the service providers prepared a monthly report as required by regulation. We did not look at these during this inspection. Quality assurance questionnaires were distributed by the home and analysed monthly. Evidence was seen that where necessary responses had been made and action taken. In addition monthly audits were made of other areas of practice such as accidents, complaints, equality and diversity. This enabled weaknesses and concerns to be identified and addressed. Residents’ money held in safekeeping and managed on their behalf was stored securely and appropriately receipted and recorded. All staff had received training in matters relating to health and safety. Records were checked in respect of fire safety and accidents. These were found to be well kept and up to date. All necessary maintenance checks and testing of machinery and equipment were being carried out at the required intervals. Residents stated they felt safe and protected in their home. Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 26 Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 4 4 x x x x x x 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x 3 3 x 4 Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Regent DS0000030248.V367225.R01.S.doc Version 5.2 Page 30 - 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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