Care Home: Shottermill House

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What the care home does well People who may wish to use the service have a full needs assessment prior to using the service in order to ensure that the homes staff have the skills and abilities to meet the individuals assessed needs. People are involved in decisions about their lives and have an active role in planning the care and support they receive. Peoples health care is promoted and the care people recieve is reviewed and changes recorded. The medication processes in the home are robust to protect individuals from harm. People are protected by the homes complaints and safeguarding adults procedures. Peoples rights to dignity and respect are promoted. Peoples rights of choice about their daily routines and the range of activities and spirtual support is promoted. A variety of Visitors are welcomed to the home to maintain contact with their family members and friends. The home provides a healthy and balanced diet in spacious and pleasant surroundings. The physical design and layout of the home supports individuals to live in a safe, well maintained and comfortable environment. Staff in the home are in sufficient numbers to support the people who use the service. The management and administration of the home is robust and continues to be run in the best interests of the people living in the home. Peoples welfare is promoted through the monitoring of health and safety in the home. What has improved since the last inspection? The home have met all the previous requirements made following the last inspection. What the care home could do better: Arrangements must be made to further ensure the safety and wellbeing of people when in the garden area of the home. The control of the spread of infection needs to be more robustly managed in order to ensure the safety and well being of all people in the home. Safe recruitment and vetting of staff needs to be more robust in order to protect the welfare and safety of individuals in the home. The storage of food in the homes fridges must comply with the standards of safe food handling in order to ensure the well being and welfare of all people in the home. Key inspection report Care homes for older people Name: Address: Shottermill House Pilgrim Homes Liphook Road Haslemere Surrey GU27 1NX     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: Suzanne Magnier     Date: 2 1 0 5 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 29 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Shottermill House Pilgrim Homes Liphook Road Haslemere Surrey GU27 1NX 01428661034 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: shottermill@pilgrimhomes.org.uk www.pilgrimhomes.org.uk Pilgrim Homes care home 31 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category physical disability Additional conditions: 1. The registered person may provide the following category/ies of service only: Care home only (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories; Old age, not falling witihin any other category (OP) Dementia (DE) Physical disability (PD) 2. The maximum number of service users to be accommodated is 31. Date of last inspection Brief description of the care home Shottermill House is a purpose built care home. It was opened in 1990 and is owned and operated by a Christian charity called Pilgrim Homes. The service provides care for elderly Protestant Christians who subscribe to the Doctrinal Basis of faith. The home is situated on the outskirts of Haslemere and is Care Homes for Older People Page 4 of 29 Over 65 0 31 0 31 0 31 Brief description of the care home convenient to the local amenities. Personal care is provided for up to thirty-one older people all of whom may be over or under the age of 65 and who may require care and accomodation due to dementia or dementia type illness. There are comfortable and spacious communal areas which include a dining room, lounge and quiet sitting area and an enclosed garden. All bedrooms are single occupancy and bathrooms are well equipped. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The Quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The last key inspection on this service was completed on the 12th December 2007. This key inspection was conducted by Ms S Magnier Regulation Inspector and lasted for six hours commencing at 09.00 hours and concluded at 15.00. The registered manager represented the service. The inspector looked at and assessed how well the service was meeting all the National Minimum Standards for Care Homes for Older People and has in this report made judgements about the standard of the service. The service had completed the Annual Quality Assurance Assessment AQAA which includes information from a variety of sources. This initially helps us to prioritise the Care Homes for Older People Page 6 of 29 order of the inspection and identify areas that require more attention during the inspection process. This document was received by the commission was noted as being well documented and is referred to within the report. The information contained in this report was gathered from observation by the inspector, speaking with a number of individuals living at the home, a health care professional visting the home, some care staff and information contained within the AQAA. Further information was gathered from records kept at the home. A full tour of the premises was undertaken and documents sampled during the inspection included peoples care plans, daily records and risk assessments, medication procedures, health and safety records, staff training and recruitment records,and some of the homes policies and procedures. The final part of the inspection was spent giving feedback to the registered manager about the findings of the visit. The commission have not received or been made aware of any notifications of complaints. One safeguarding vulnerable adults referral has been made since the last inspection which has been satisfactorily concluded. From the evidence seen by the inspector it is considered that the home would be able to provide a service to meet the needs of individuals who have diverse religious, racial or cultural needs. Care Homes for Older People Page 7 of 29 What the care home does well: What has improved since the last inspection? What they could do better: Arrangements must be made to further ensure the safety and wellbeing of people when in the garden area of the home. The control of the spread of infection needs to be more robustly managed in order to ensure the safety and well being of all people in the home. Safe recruitment and vetting of staff needs to be more robust in order to protect the welfare and safety of individuals in the home. The storage of food in the homes fridges must comply with the standards of safe food handling in order to ensure the well being and welfare of all people in the home. Care Homes for Older People Page 8 of 29 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 29 Details of our findings Contents Choice of home (standards 1 - 6) Health and personal care (standards 7 - 11) Daily life and social activities (standards 12 - 15) Complaints and protection (standards 16 - 18) Environment (standards 19 - 26) Staffing (standards 27 - 30) Management and administration (standards 31 - 38) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may wish to use the service have a full needs assessment prior to using the service in order to ensure that the homes staff have the skills and abilities to meet the individuals assessed needs. Evidence: The homes registered manager and the staff member assigned as the head of care demonstrated, through the care plans sampled, that they understood the importance of having sufficient information through the completion of a full needs assessment for all people considering admission to the home. There was evidence to support that the care needs assessments had been completed with the individual or their representative prior to admission to the home. Admissions to the home only take place if the management team are confident that the homes staff have the skills and experience to support the individuals assessed needs. Care Homes for Older People Page 11 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are involved in decisions about their lives and have an active role in planning the care and support they receive. Peoples health care is promoted and the care people recieve is reviewed and changes recorded. The medication processes in the home are robust to protect individuals from harm. Peoples rights to protection, dignity and respect are promoted. Evidence: It was obsereved that people remain in control of their daily lives and moved around the home and garden area freely. Several individuals confirmed that they have choices about where to be during the day which included staying in their room, being in the main lounge area, walking in the garden or being in the other places in the home. The three care plans sampled evidenced that individuals and their representatives had been involved in the development of their care plans. The care plans demonstrated sound evidence of individuals equality and diversity. The care plans sampled were person centred and included a range of information Care Homes for Older People Page 12 of 29 Evidence: about the individual for example their life experiences and social history, how they like to communicate, their skills and abilities, and how they like to make choices in their lives and how the individuals health care needs are met. People spoke highly of the care and attention they receive from the staff and throughout the day the inspector observed that people were addressed in a polite and courteous way by all staff and there was evidence of meaningful professional relationships between staff and people at the home. There was evidence to support that the home has maintained links with the local general practitioner who visits the home regularly. The district nurse visiting the home spoke highly of the care and attention people receive at the home and advised the home was well managed and staff efficient. Visits by the district nurse are arranged for individuals who require specfic interventions and referrals to other health care professionals are made in order to maintain the health and welfare of all individuals at the home. Through sampling care plans it was evident that people are visited by the chiropodist, opticians and visits for dental treatment and other specialist health care appointments are arranged when necesary. Documented plans for assessing individuals nutrition and the management of their body weight were evidenced and where necessary pressure releiving equipment is used to promote good tissue viability. The standard of documented care plans were excellent and up to date. There was evidence that the plans were reviewed regularly to reflect the changing needs of the individual and where possible the individual and their family or significant person had supported staff to develop the care plan. The care plans contained comprehensive risk assessments, including falls risk assessments, which were reviewed and sampled as current to reflect the hazards being presented in the persons life and the measures in place to reduce the hazards as far as reasonably practicable. The homes management have sought additional information relating to peoples human rights with regard to limitations on freedom and mental capacity, choice and promote the best interests of people living at the home. There was evidence to support that peoples rights to citizenship were supported through access to visiting polling stations or postal voting. The home has a medication policy and procedure in place and continues to use a monitored dosage system. Medication records were well documented. The procedures for ordering, delivery and disposal of medicines were robust. Training records evidenced that senior staff who administer medicines had received appropriate Care Homes for Older People Page 13 of 29 Evidence: training. Whilst speaking with staff it was confirmed that people have a right to refuse to take medication and if the refusal continued external advise would be sought in order to ensure the well being of the individual. Care Homes for Older People Page 14 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples rights of choice about their daily routines and the range of activities offered is promoted. Visitors are welcomed to the home to maintain contact with their family members and friends. The home provides a healthy and balanced diet in spacious and pleasant surroundings. Arrangements must be made to further ensure the safety and well being of people when in the garden area of the home. Evidence: As previously documented it was observed that peoples rights to live an ordinary and meaningful life were promoted and where people chose to get up late, stay in their room or wander around the home or garden these activities were accepted by staff in order to promote the persons autonomy and respect their choices. As a registered care home supporting elderly Christians a central principle is the spiritual support through prayer and fellowship which is promoted on a daily basis. The morning service, conducted by a volunteer speaker was well attended by individuals and people confirmed that they are able to continue to have contact and fellowship with their own churches. Care Homes for Older People Page 15 of 29 Evidence: People were observed to read the activities programme displayed within the home and confirmed that a variety of social events and activities take place. The notice board and activities programme demonstrated that a variety of activities and meaningful engagements were on offer that included board games, crafts, cooking, coffee mornings, music for health, mobile library, aniversary services, television and DVDs, music entertainment, PAT dogs, manicures, scrabble and poetry are some of the activities provided within the home. Visits to local garden centres and entertainment coming to the home has included Pantomines, mobile farms, carol concerts and visits from school age children. The AQAA advises that a therapeutic activities manual has been introduced and additional games, stereo unit and craft items have been purchaesd. The home plan to research the need and potential funding sources for an adapted vehicle which would enable easier access to local venues and enhance the the provision of activities. It was observed that the garden area was accessible to people living at the home yet areas of the garden were uneven and were viewed as potentially hazardous. There were no hand rails available and one individual was observed to stagger down a sloped area in the garden. The manager confirmed that he had recognised this hazard, which was documented within the AQAA and it is required that arrangements must be made that all parts of the home to which individuals have access are so far as reasonable practicable free from hazards to their safety. The home have open visiting hours and several visitors were in the home during the inspection and observed to be relaxed and engaging with people and staff. Recent letters of compliment were displayed on the notice boards and events of note for example the visits made by the local mayor to participate in special birthday celebrations. The menu displayed throughout the home offered a variety and choice of meals. Comments about the meals were favourable and it was observed that the midday meal was well presented, hot and served in a efficient manner. The dining area was spacious and contained small tables which had been had been set with appropriate condiments, crockery, tablecloths and napkins. Specialised cutlery was available for some individuals, and named placemats supported individuals to their places at the tables. Staff supported individuals who needed assistance in a discreet and dignified manner and, where able, some individuals served their own vegetables from serving dishes on their tables. The AQAA advises that visitors are encouraged to take meals at the home if they choose to. Care Homes for Older People Page 16 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are protected by the homes complaints and safeguarding adults procedures. Evidence: The home has an established complaints procedure which was evidenced as an up to date document and was available throughout the home. It was confirmed whilst speaking with the registered manager and with reference to the AQAA that two complaints have been received by the home since the last key inspection. Documentation sampled confirmed that the registered manager had responded promptly and effectively to the complaints received and satisfactory conclusions had been reached. Various people told the inspector that they knew how to make a complaint if they were unhappy but felt that the home was nice and they would have little to complain about. It was observed that the managers and staff were aware of an individuals anxiety at particular times of the day and staff were seen to be prompt to recognise this and assist the individual by offering reassurance and support. The security of the home was robust and a key pad system has been installed at the front entrance to the home and other doors to the home were security alarmed. People entering the home signed the visitors book and the homes garden was fully enclosed to offer security for individuals. Three staff files sampled evidenced that Care Homes for Older People Page 17 of 29 Evidence: Criminal Record Bureaux checks and Protection of Vulnerable Adult checks are carried out on all new staff. The home has a copy of the Surrey County Council Multi agency Procedures for Safeguarding Vulnerable Adults. The homes policy regarding the safeguarding of vulnerable adults was sampled and it was evidenced that the policy complied with the local authorities protocols. It was confirmed that one safeguarding referral had been made since the last key inspection and had been satisfactorily concluded. Records sampled evidenced that all staff had received safeguarding vulnerable adults training and where staff were due to attend the training this had been booked. The home has a whistle blowing procedure in order that staff are aware of their duty of care to report any safeguarding incidents. The registered manager has been procative in attending training, seeking additional information and assessing situations regarding the Mental Capacity Act and the Deprivation of Liberty Act for some individuals who may lack capacity. The training has been cascaded to senior staff in the home in order to ensure the protection of the individuals receiving care and accomodation at the home. Care Homes for Older People Page 18 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The physical design and layout supports individuals to live in a clean, safe, well maintained and comfortable environment. The control of the spread of infection needs to be more robustly managed in order to ensure the safety and wellbeing of all people in the home. Evidence: The location and layout of the home remains suitable for its stated purpose and the home continues to provide pleasant surroundings for individuals with suitable furniture and soft furnishings throughout the home for people to use. The home was well maintained and an extensive redecoration programme has been undertaken during the last twelve months. New flooring has been laid to some bedrooms and ensuite facilities and communal and visitors toilets, new dining room chairs have been purchased, the entrance hall and main lounge area have been redecorated, the lounge includes a newly created nostalgic corner with photographs, display cabinets and wall plates and offers a quiet area within the main lounge. A new dishwasher has been installed and emergency lighting updated. The staff dining room has been decorated and a new dining table supplied and outdoor seating for all people to use has been purchased. During the tour of the premises the hairdressing suite was seen and it was suggested that the room be arranged in a more creative way that helps people to have a sense Care Homes for Older People Page 19 of 29 Evidence: that they are visiting a hairdresser. It was observed that the window of one vacant bedroom on the first floor was not fully resrticted and this was brought to the registered managers attention and was immediatly rectified by the homes maintainence officer in order to ensure the safety and well being of any resident residing in the room. All bathroom and toilet facilities were sampled and it was confirmed by the registered manager that they meet the current needs of individuals at the home. One bathroom area has been recently designed with a walk in shower unit which has been of benefit to individuals living in the home and there are proposals to incorporate more walk in shower units in the future. The inspector noted that the general standard of cleanliness and hygiene throughout the communal areas of the home was good yet the control of infection in the home was not appropriatly managed regarding the disposal of waste and the storage of soiled linen in the laundry room. It has been required that arrangements to control the spread of infection in the home must be more robust in order to ensure the safety and well being of all people in the home. Staff were seen to wear protective clothing for all tasks undertaken in the home and handwashing facilities were available to all people throughout the home. Care Homes for Older People Page 20 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are in sufficient numbers to support the people who use the service. Safe recruitment and vetting of staff needs to be more robust in order to protect the welfare and safety of individuals in the home. Staff receive training to ensure peoples needs are appropriatly met. Evidence: During the inspection it was observed that the home was adequatley staffed at all times and staff were at hand to meet the needs of individuals. The home employs eighteen care staff of mixed gender, seven of whom have achieved their National Vocational Qualifications in level 2 or above. The registered manager advised that he offers an open door policy within the home and there are six senior staff within the staff team who provide hands on care and support to individuals living at the home and offer support and mentorship to staff. The general atmosphere was quiet and orderly and staff were observed to undertake their duties in an efficient and professional manner. Staff relationships with individuals were professional and the use of terms of endearment supported trusting relationships between the individual and the staff member. Peoples preferences on how they like to be addressed were documented in peoples care plans. Care Homes for Older People Page 21 of 29 Evidence: The home has a recruitment and selection policy, which incorporates equal opportunities. The inspector sampled two care staff files and one anciliary staff members file. Both care staff files lacked sufficient evidence of safe vetting procedures due to the lack of two written references from the persons previous employers and one application form was not comprehensively completed. There was evidence that face to face interviews had taken place, a job description was available in order that the staff member was clear about their roles and responsibilities and there was documented evidence that a CRB clearance had been obtained in conjunction with a POVA first check. Following the inspection it was agreed with the registered person that the identified care staff must be supervised whilst working in the home care until such time as satisfactory relevant references are obtained. The registered manager has given assurances to the commission that references for the individuals have been sought following the inspection and he will continue to keep the commission updated on this matter. It has been required that safe vetting practices concerning the recruitment of staff must be more robust in order to ensure the safety and protection of people in the home. The registered manager confirmed that the home is committed to the ongoing training and development of staff and the staff files and training matrix detailed that staff have attended induction, statutory training and specialist training, including training to support people with dementia in order to provide care and support to individuals with specfic needs. Care Homes for Older People Page 22 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is robust and continues to be run in the best interests of the people living in the home. Peoples views and opinions and those of others associated with the home are sought. Peoples welfare is generally promoted through the monitoring of health and safety in the home yet improvements must be made regarding the storage of food in the homes fridges. Evidence: The management of the home is robust and based on openess and respect. The registered manager demonstrated throughout the inspection a knowledge and understanding of the day to day running of the service for the benefit of the people living at the home. It was confirmed that the registered manager continues to receive and undertake training for example the deprivation of liberty, equality and diversity and dementia training in order that he has the knowledge and skills to continue the effective management of the home. It was evident during the inspection that the homes staff have open and professional relationships with the homes management and individuals living in the home. Care Homes for Older People Page 23 of 29 Evidence: The home has an internal Quality Assurance process and there was evidence to support that the views from people living in the home had been instrumental in changing some of the aspects in the home which have included moving the hymn board in the lounge so it can be more easily seen, arranged a nutritionalist to meet with the cooks and senior staff to ensure that the home are meeting the nutritional needs of individuals. Resident meetings are held regularly to discuss updates and future plans of the home and an amplication system is available for people with hearing impairments. Questionaires are distributed throughout the home and also given to visitors and the results used to monitor the quality of the service and discussed with people associated with the home. Regulation 26 records of an unannounced visits by nominated members of the Home Support Group, who are appointed by the Trustees were evidenced and the records were thorough in assessing the quality of the service and any issues identified would be noted by Pilgrim Homes in order that appropriate action would be taken to rectify the shortfalls. The storage of chemicals in the home were appropriate to ensure the safety and welfare of all people in the home. The fridge, freezer and pantry were well stocked. Fresh fruit and vegetables were available for individuals. Records of food temperatures were sampled and well recorded. The storage of food in the main kitchens fridge was not in compliance with food hygiene standards as several items of food were not covered and there was no indication of when items of food, for example cheese, had been opened. It has been required that arrangements must be made that the storage of food within the homes kitchen must be more robust in order to ensure peoples welfare and well being. The homes fire procedures sampled confirmed that records were kept of fire tests and equipment checks and signage was available within the home to show people fire exits. The registered manager confirmed that peoples finances are safeguarded through the appointments of enduring powers of attorney. The home has a current certificate of registration and insurance and the recording of accident and incidents has been maintained with the commission continuing to be Care Homes for Older People Page 24 of 29 Evidence: informed promptly of events which affect the well being and welfare living in the home. Care Homes for Older People Page 25 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 26 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 16 Arrangements to control the spread of infection in the home must be more robust. In order to ensure the safety and wellbeing of all people in the home. 15/06/2009 2 12 13 Arrangements must be 31/08/2009 made that all parts of the home to which individuals have access are so far as reasonable practicable free from hazards to their safety. In order to ensure peoples safety and wellbeing. 3 29 19 Safe vetting practices 31/08/2009 concerning the recruitment of staff must be more robust at all times. In order to ensure the safety and protection of people in the home. Care Homes for Older People Page 27 of 29 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 4 38 13 Arrangements must be made that the storage of food within the homes kitchen must be more robust. In order to ensure peoples welfare and well being. 15/06/2009 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 28 of 29 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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. 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