Care Home: Siegen Manor

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What the care home does well The manager wrote in the AQAA: “We provide intermediate care with dementia, mainstream and dementia service in dedicated facilities, as well as respite services. We provide a well trained team with a high emphasis on their development. We have person centred approaches at the forefront of our development and intervention, the extension of life story work and memory box contributes to maintaining person hood for our customers.” “We are flexible and responsive to varied needs and provide multi agency services in order to provide high quality care.” People said: “I’m quite satisfied with Siegen Manor” Staff said: Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 “I feel we provide a calm, homely atmosphere” Healthcare professionals said: ““Overall excellent care and communication” “Always get a warm greeting” “I have only ever observed positive interaction between staff and customers” There is a clear commitment at the home to provide high quality care to people staying or living at the home. Staff are well trained to look after the care needs of people admitted for social care or in need of dementia care. People have their needs assessed before they move into the home and the admission process is well managed with visits and overnight stays encouraged helping people make up their mind about moving into the home. People are supported and encouraged to spend their time in the way they want. What has improved since the last inspection? The manager wrote in the AQAA about what had improved over the last 12 months: “The environment has continued to be adapted to meet the specialist needs of the customers. Investment has been made in facilities for reminiscence work and entertainment equipment for all. The emphasis on staff training has redoubled and is intrinsic in development of future services. Quality initiatives have improved in range and intensity.” “User consultation and emphasis on their involvement has increased.” “Dignity audits and dementia care mapping have enhanced the service and experience for our customers. Stability in the management team has been secured and team confidence has subsequently improved.” There has been a change of manager and the new manager has worked hard with the staff for continued improvement of the care and facilities at the home. Care records provide much more detail for staff so that they understand how to approach and care for people. What the care home could do better: The manager wrote about plans for improvement in the next 12 months: “A continued emphasis on Person centred care will be fed through the development of fully integrated life story work. The manager and officers will continue a programme of dementia care mapping in order to improve performance of the team and the experience of our customers.”Siegen ManorDS0000033232.V374959.R01.S.doc Version 5.2 “The lifestyle plans will continue to receive a continued high degree of attention and training will be provided for all new team members, further improving the care planning skills and record keeping of the staff team.” “The sensory garden project will be secured/pursued and efforts to improve the grounds to extend external activity choice and provide a place for solitude and contemplation will be completed.” “Person centred approaches will continue to be introduced and evidence based best practice for the specialities of dementia and intermediate care/rehabilitation, used to develop the service.” The information provided by the manager for the next year demonstrate the ongoing commitment to the sustained and continued improvement of care and facilities at the home. Key inspection report CARE HOMES FOR OLDER PEOPLE Siegen Manor Wesley Street Off Odd Fellow Street Morley Leeds LS27 9EE Lead Inspector Catherine Paling Key Unannounced Inspection 16th April 2009 09:45 DS0000033232.V374959.R01.S.do c Version 5.2 Page 1 This report is a review of the 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. 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. Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 2 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 Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Siegen Manor Address Wesley Street Off Odd Fellow Street Morley Leeds LS27 9EE 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) 0113 2536155 0113 3074569 Leeds City Council Department of Social Services Christopher Peters Care Home 30 Category(ies) of Dementia (16), Old age, not falling within any registration, with number other category (14) of places Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code 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 within any other category - Code OP; Dementia - Code DE The maximum number of service users who can be accommodated is: 30 25th April 2007 2. Date of last inspection Brief Description of the Service: Siegen Manor is a purpose built home for older people located near the centre of Morley, south of Leeds. Leeds Local Authority manages and operates the home. There is a day centre attached that is managed and operated separately from the home. The home provides personal care for up to 30 people. There are 14 beds dedicated to the care of people with dementia and 5 beds for people admitted to the home for intermediate care. Nursing care is not provided and the local district nursing service provides nursing support if needed. The home is divided into four wings each with sitting, dining areas, a small kitchenette and bathrooms. Walk in showers and assisted bathing facilities are available. There is a well-equipped visitors’ lounge where residents can sit with their families or use for private visits. Accommodation is provided in mostly single rooms with a small number of shared rooms available. Information about the service is available in a Statement of Purpose and Service User Guide as well as a brochure. These documents are reviewed regularly to make sure that the information is up to date. The fees range from £102.90 to £510.30 per week. There are additional charges for hairdressing and newspapers. This information was provided by the service in April 2009. The home should be contacted directly for up to date information about charges. Siegen Manor DS0000033232.V374959.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 three stars – excellent service. This means the people who use this service experience excellent quality outcomes. This was an unannounced visit by one inspector who was at the home from 09:45 until 16:15 on 16th April 2009. The purpose of the inspection was to make sure the home was operating and being managed for the benefit and well being of the people who live there and in accordance with requirements. Before the inspection accumulated evidence about the home was reviewed. This included looking at any reported incidents, accidents and complaints. A number of documents were looked at during the visit and most of the areas of the home used by the people who lived there were visited. A good proportion of time was spent talking with the people who live at the home, as well as the staff and the manager. An Annual Quality Assurance Assessment (AQAA) had been completed by the home before the visit to provide additional information. This is a selfassessment of the service provided. Survey forms were sent out to the home before the inspection providing the opportunity for people at the home, visitors and healthcare professionals who visit, to comment, if they wish. Information provided in this way may be shared with the provider but the source will not be identified. A number of surveys were returned by the time of this visit. Comments received appear in the body of the report. What the service does well: The manager wrote in the AQAA: “We provide intermediate care with dementia, mainstream and dementia service in dedicated facilities, as well as respite services. We provide a well trained team with a high emphasis on their development. We have person centred approaches at the forefront of our development and intervention, the extension of life story work and memory box contributes to maintaining person hood for our customers.” “We are flexible and responsive to varied needs and provide multi agency services in order to provide high quality care.” People said: “I’m quite satisfied with Siegen Manor” Staff said: Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 6 “I feel we provide a calm, homely atmosphere” Healthcare professionals said: ““Overall excellent care and communication” “Always get a warm greeting” “I have only ever observed positive interaction between staff and customers” There is a clear commitment at the home to provide high quality care to people staying or living at the home. Staff are well trained to look after the care needs of people admitted for social care or in need of dementia care. People have their needs assessed before they move into the home and the admission process is well managed with visits and overnight stays encouraged helping people make up their mind about moving into the home. People are supported and encouraged to spend their time in the way they want. What has improved since the last inspection? What they could do better: The manager wrote about plans for improvement in the next 12 months: “A continued emphasis on Person centred care will be fed through the development of fully integrated life story work. The manager and officers will continue a programme of dementia care mapping in order to improve performance of the team and the experience of our customers.” Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 7 “The lifestyle plans will continue to receive a continued high degree of attention and training will be provided for all new team members, further improving the care planning skills and record keeping of the staff team.” “The sensory garden project will be secured/pursued and efforts to improve the grounds to extend external activity choice and provide a place for solitude and contemplation will be completed.” “Person centred approaches will continue to be introduced and evidence based best practice for the specialities of dementia and intermediate care/rehabilitation, used to develop the service.” The information provided by the manager for the next year demonstrate the ongoing commitment to the sustained and continued improvement of care and facilities at the home. 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. Siegen Manor DS0000033232.V374959.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 Siegen Manor DS0000033232.V374959.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 People using the service experience good quality outcomes in this area. People have enough information to be able to make an informed choice about moving into the home. The admission process is good and includes introductory visits wherever possible. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager wrote in the AQAA – “The literature provided to potential and actual customers is both varied and imaginative. This information is reviewed at least twice yearly.” Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 10 “All potential customers have a pre-visit were they would receive an information pack, when they visit the home. If, after the visit, they are still undecided whether they would like to use the service, we may arrange an overnight stay to support the decision making. While the customer is participating in a pre-visit, we complete a pre-assessment which enables us to identify individuals needs and the customer to ‘get a feel for the service.’ Relatives and friends are encouraged to come and visit the home so they can make an informed choice.” “We provide 5 rooms which are used for intermediate care customers, who are also living with dementia. We have dedicated joint working partnerships with specialist providers such as physiotherapy as well as medical cover specifically for intermediate care and nursing cover both general and mental health.” We found that there is a lot of information for people about the service to help them make up their minds about moving in. People and their relatives are encouraged to visit the home as part of the pre-admission assessment process and can even have an overnight stay to help them make a decision. People we spoke to said that they felt their admission to the home had been well managed and that they had enough information given to them. There are specific bedrooms for people admitted for intermediate care. We saw that there is very good information for people about this service in the bedrooms as well as other information displayed in the main entrance. Siegen Manor DS0000033232.V374959.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience excellent quality outcomes in this area. Staff have access to detailed information about people and the care they need so that they know how to look after people properly. People are protected by safe medication procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager wrote in the AQAA: “All customers have a pre-assessment before they are admitted, except where intermediate care needs may make this impractical. Prior to commencing with the service we receive a care plan from the social worker giving details regarding the customers individual needs. All the information received in the Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 12 care plan, our assessment, information from the residents, family/friends and the key worker is collated to develop a comprehensive individual life style plan.” “All primary care needs are met and the resident has access to specialist services and facilities such as the district nurse, dentist, chiropodist, OT, mental health specialists etc. Intermediate care customers are provided with dedicated health care services with all specialisms, such as occupational therapy, general and psychiatric nursing service and physiotherapy.” “Customers are encouraged to self medicate and are supported to do so if they wish within a risk assessment framework.” “Only staff who have had training in medication administration are authorised to dispense medication to residents.” Staff said: “We promote person centred care” Health care professionals said: “Advice requested promptly and appropriately” “Very personalised care “Staff always seem to know individuals very well” “V. helpful to visiting doctors” “I am very impressed with the service.” People said: “I’m quite satisfied with Siegen Manor” We looked in detail at the care of a small number of people staying or living at the home. This included people staying at the home for respite care as well as people living at the home on the older persons unit and on the dementia care unit. The records we saw had very good information for staff about how to look after people properly. For one person who showed some challenging behaviour there was very detailed information so that staff understood what the ‘triggers’ were so that they knew how best to approach and support this person. We spent time with people on the dementia unit and when we looked at their care records they gave a clear picture of the people we had spent time with. This means that staff have access to detailed and accurate information about the people they care for. We saw excellent pen pictures had been developed about people with dementia involving other members of their families. This gives staff a full picture and helps them to understand the person where communication is difficult. Care plans had been reviewed and updated where necessary so that staff have access to up to date information. Daily notes show how people have spent their time and the care or support they have needed. We looked at the records of one person admitted to the home for respite care. Although we saw a very well completed support plan for this person the form was undated and unsigned. There was also a need for clarification on some of Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 13 the information. For example, the care plan stated that he ‘may need help’ with personal hygiene but there was no further detail to tell staff if this person did need help and if so what sort of help. The night care plan also noted no night time checks but daily records stated ‘asleep all checks to 6am’. Overall, the records were good but staff need to make sure that the there is enough detail for people staying at the home on a temporary basis so that any care needs are not overlooked. There was good evidence of the involvement of other healthcare professionals with, for example, clear records of visits by the General Practitioner (GP). People we spoke with were satisfied with their care. We also spoke with some visiting relatives who were also pleased with the support and care people received. There was a detailed medication audit completed in December 2008 with a good outcome. There are regular medication reviews and any staff involved in the administration of medication have been properly trained. There have been some medication errors since our last visit. These have been notified to us as required and the correct action has been taken in every case. A privacy and dignity audit was completed at the home by Age Concern in 2008. We saw the results of this audit: “(Siegen Manor) provides a warm safe and homely environment” “relaxed atmosphere” “very positive communications”. Siegen Manor DS0000033232.V374959.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience excellent quality outcomes in this area. People are supported in maintaining contact with family and friends and to make choices. People are provided with a good and varied diet that takes individual choice into account. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Key inspection 15/04/09 The manager wrote in the AQAA: “We have both internal and external activities a daily (activity record) plan is compiled in consultation with the customers. Their interest and hobbies and what each individual would wish to be doing in the next month or so is actioned. Links with the community are encouraged. We are pursuing the full Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 15 integration of life stories for those living with dementia, work has commenced on this project.” “A picture menu is available to assist in making choices. The chefs provide for individual choices over and above menu wherever possible.” “Visiting times are open and encouraged.” “We are part of dignity project and welcome this independent qualitative support for the service.” People said: “I would like to see more choice of both main course and sweet” “I’m happy enough and glad I’m not on my own” People are able to spend their time in the way they want. On the day of our visit one person was going out with a friend for lunch and then around the local shops, another was going out to a meeting. Relatives are made very welcome at the home and are able to join in social events. Regular Newsletters are produced and we saw the most recent one distributed around the home. The Newsletter provides update about developments at the home and also informs people about the quality surveys sent out to people and their relatives. There are regular activities through the day and into the evening such as bingo and dancing. A recent purchase of a Wii console was providing and additional source of entertainment for people. Information, including photographs, of recent activities are displayed in wall mounted boxes so that relatives are aware of events at the home. We saw that staff are working with people on the dementia unit to develop memory boxes. One person showed us their memory box which prompted memory and discussion about important life events. This person was very pleased to share the memory box with us during the visit The main meal of the day is served in the evening with a light lunch of soup, sandwiches and sweet served at lunchtime. The lunchtime meal was well managed and people seemed to enjoy their food. Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. There is a clear complaints procedure available to people at the home. The people who live at the home can feel confident that they will be listened to and can be assured that action will be taken when necessary. People are protected by safeguarding procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager wrote in the AQAA: “We have a robust complaints/compliments system which responds immediately to any issues raised and we learn from our mistakes. We view complaints as a positive and indeed encourage them so that we may learn from mistakes and use these as a basis for change.” “Staff are trained in safeguarding adults issues, any safeguarding issues would be attended to immediately in line with policy requirements, referrals are made to the safeguarding adults unit when required.” Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 17 There is a clear complaints procedure available to people who have concerns about the service they receive. We saw that clear records are kept and demonstrated that concerns are taken seriously and dealt with properly. Staff have training in safeguarding vulnerable adults and were clear about the action they should take if they had any safeguarding concerns. There have been some safeguarding concerns since the last visit and the provider has acted appropriately in addressing the concerns to make sure people are kept safe and informing us of their actions, as is required. Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. People live in a safe, comfortable and well maintained environment. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager wrote in the AQAA about improvements over the last 12 months: “New fire system with all new doors and sprinklers has been fitted. New none slip flooring has been fitted to some main areas and bedrooms. Orientation signs have been improved. Specialist carpets for dementia care have begun to be fitted. Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 19 Conservatory has been completed.” The manager wrote in the AQAA about planned improvements for the next 12 months: “All main bathrooms and toilets are to be upgraded. The redecoration plan is ongoing, with the consultation of our customers. On-going review of risk assessments, with audits completed by the manager. 24hour café facility to be provided in conservatory with risk assessment framework. Provision of wall mounted memory box displays, for all customers living with dementia. Further environmental changes to further improve orientation for those with dementia. Garden and surrounding areas to be upgraded and plans for sensory garden pursued.” From the privacy and dignity audit: “clear and effective use of signage” “excellent” We saw that work has been carried out since the last visit to upgrade the environment and has been completed to a high standard. We saw that there are good infection control practices in place at the home. Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. People are cared for by a team of trained and competent staff. There are enough staff to look after people properly. People are protected by robust recruitment procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager wrote in the AQAA: “We have a robust recruitment and selection process, underpinned by a robust equal opportunities policy.” “Staffing levels are reviewed on a daily basis ensuring that ratios reflect the needs of the customers.” Staff said: “There has been a spell where agency has had to be used. Its not good for service users to keep seeing different faces.” Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 21 “Due to long term sickness sometimes we are very short staffed. Having to use agency workers.” “Information (about care needs) given as soon as a need also in monthly staff meetings care needs and changes are discussed in full.” “We have lots of training some are repeated yearly.” “We have six supervisions per year and a yearly appraisal.” “I feel we provide a calm, homely atmosphere” Health care professionals said: “Great skill mix appropriately used” We spoke with staff and saw that there were overall good levels of staff on duty including 3 staff over night. There have been problems with sickness but the manager is committed to keeping staff changes to a minimum to make sure that people have stability of staff and continuity. Staff have good opportunities for training to make sure that they have the skills to look after people properly. This training includes specific dementia care training for all staff. We looked at a small sample of individual staff recruitment records and saw that all the required checks are completed for people before they start work at the home. Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. The home is well managed and is run in the best interests of the people who live there. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager wrote in the AQAA: Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 23 “The manager has many years experience of working with older people and managing social care services. Qualification requirements are well exceeded and professional development is incorporated into practice and principles. The manager has a background in dementia care and has specialist knowledge and training skills.” There has been a change of registered manager since our last visit. The new manager is a qualified registered mental nurse (RMN) and maintains his registration with the Nursing and Midwifery Council (NMC) through regular update. However, regulation requires him to consult with the community nursing service where people at the home have nursing needs. He has also completed other training relevant to his role as registered manager of the service. The manager uses a range of audits to help him to monitor the service and facilities. The outcome of the medication audit led to a review of practice which has resulted in a reduction in medication errors. Regular audits are done of the care plans. There is clear identification of shortfalls as well as what is good in the records. Where shortfalls are identified there is a deadline for action by staff. People who use the service and other interested parties are surveyed regularly. Results are analysed and an action plan developed to address any issues identified through the survey. The manager involves people, their families and staff in the running of the home through meetings and newsletters. From the home’s 2009 survey:Healthcare professionals said: “Overall excellent care and communication” “Always get a warm greeting” “I have only ever observed positive interaction between staff and customers” Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 24 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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 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 3 X 3 X 3 X X 3 Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 25 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 Siegen Manor DS0000033232.V374959.R01.S.doc Version 5.2 Page 26 Care Quality Commission Yorkshire and Humberside Region Citygate Gallowgate Tyne and Wear NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshireandhumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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