Care Home: Sloe Hill Residential Care Home Limited

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What the care home does well We found that the atmosphere in the home is welcoming and friendly. The residents told us that they are very happy with their lives at Sloe Hill and feel that they are well cared for and the staff provide the care and support in a way that they prefer. The manager has an on going training programme in place to ensure the staff have the skills and competences to carry out their role. There is a full programme of activities on offer including outings that are chosen by the residents. The home provides an excellent choice of food that is enjoyed by most of the residents and alternatives are offered if the choices of the day are not to their liking. Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 To ensure that residents and visitors have access to up to date information there are various pieces of information about the home and the activities that residents take part in and this is available in the front entrance to the home including a copy of the Statement of Purpose, Service user Guide and the most recent inspection report and a photo album of the activities that have taken place. What has improved since the last inspection? All staff have completed level 2 in Dementia Care, which provides them with the knowledge and understanding of the needs of those residents who have a dementia diagnosis. All except one bedroom now have an e-suite toilet and sink provided and this ensures that residents independence and dignity is upheld and they do not have far to travel when in their rooms to meet their toileting needs. The upper floor has been raised to provide a level surface which now allows all residents to access the lift and the bathing facilities even if they have some mobility problems. To give the residents’ choice on bathing they have provided a shower room. An additional medication trolley has been provided which provides more space for the medication and reduces the risk of errors. Sloe Hill residents have the use of an advocacy service through Age Concern to those residents who have little or no relatives to assist to support them in their decision making. What the care home could do better: Some work needs to be done on care planning to make them more person centred for the residents and give more detailed information about their care needs and how they would like them to be met. The activity programme information would be easier for people to access if it was produced in a pictorial format. A diabetes information session should be held to ensure that staff are clear on the needs of people who have diabetes and can provide them with the appropriate support. A risk assessment was needed for the resident who takes warfarin to ensure that they are safe and are protected should an accident occur. We noted that this was addressed during the inspection.Sloe Hill Residential Care Home LimitedDS0000037036.V377466.R01.S.doc Version 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE Sloe Hill Residential Care Home Limited Mill Lane St Ippollitts Nr Hitchin Hertfordshire SG4 7NN Lead Inspector Alison Butler Key Unannounced Inspectio 30 September 2009 10:00 th DS0000037036.V377466.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. Sloe Hill Residential Care Home Limited DS0000037036.V377466.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 Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sloe Hill Residential Care Home Limited Address Mill Lane St Ippollitts Nr Hitchin Hertfordshire SG4 7NN 01462 459978 01462 437497 sloehill@hotmail.com www.sloehill@hotmail.com Lazyday Investments 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) Martin Kelly Care Home 28 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (28), Physical disability (28) of places Sloe Hill Residential Care Home Limited DS0000037036.V377466.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 Physical Disability - Code PD Dementia - Code DE The maximum number of service users who can be accommodated is: 28 10 May 2007 2. Date of last inspection Brief Description of the Service: Sloe Hill is an independently run home owned by Lazydays Investments Ltd. It is situated down a narrow lane about mile from Hitchin town centre. It is a large attractive Edwardian house set in two acres of grounds overlooking a rural setting of villages, farms and fields. The home is registered to provide personal care to 28 elderly persons. It has a total of 25 bedrooms, 2 of which may be shared by 2 people. Accommodation is on 2 floors served by a passenger lift. The ground floor comprises an entrance lobby, lounge, lounge/diner, conservatory, dining room, main kitchen, kitchenette, laundry, 19 bedrooms all with en-suite, 1 assisted bathroom, a shower room and a total of 4 WC’s. The first floor comprises of 6 bedrooms, 5 with en-suite, 1 assisted bathroom, and a WC. There is parking around the front and side of the home. There is a table in the entrance hall of the home where a wide range of information is displayed, including the home’s Statement of Purpose, Service User’s Guide and current inspection report. For up to date fees contact the homes manager. Sloe Hill Residential Care Home Limited DS0000037036.V377466.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 quality outcomes. The information in this report is based on a visit to Sloe Hill by one inspector. The last key inspection was conducted on 10th May 2007, then in 2008 we conducted an Annual Service Review (ASR) this is our assessment of risk within a service when we have not done a key inspection in the last year. We have reviewed the information received about Sloe Hill between our visits. This includes the Annual Quality Assurance Assessment (AQAA). Each year managers of care services are required to send us their Annual Quality Assurance Assessment. This document tells us how well outcomes for people using the service are being met. It also provides us with some numerical data. We have also reviewed the notifications we receive about accidents and incidents in the home. We have not received any complaints about this service between our visits or been contacted directly by any other professionals who have contact with the people who live at Sloe Hill. As part of the inspection we talked to the residents, staff and managers who were available about the care and support that is provided. We also examined the care and administration records. What the service does well: We found that the atmosphere in the home is welcoming and friendly. The residents told us that they are very happy with their lives at Sloe Hill and feel that they are well cared for and the staff provide the care and support in a way that they prefer. The manager has an on going training programme in place to ensure the staff have the skills and competences to carry out their role. There is a full programme of activities on offer including outings that are chosen by the residents. The home provides an excellent choice of food that is enjoyed by most of the residents and alternatives are offered if the choices of the day are not to their liking. Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 Page 6 To ensure that residents and visitors have access to up to date information there are various pieces of information about the home and the activities that residents take part in and this is available in the front entrance to the home including a copy of the Statement of Purpose, Service user Guide and the most recent inspection report and a photo album of the activities that have taken place. What has improved since the last inspection? What they could do better: Some work needs to be done on care planning to make them more person centred for the residents and give more detailed information about their care needs and how they would like them to be met. The activity programme information would be easier for people to access if it was produced in a pictorial format. A diabetes information session should be held to ensure that staff are clear on the needs of people who have diabetes and can provide them with the appropriate support. A risk assessment was needed for the resident who takes warfarin to ensure that they are safe and are protected should an accident occur. We noted that this was addressed during the inspection. Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 Page 7 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. Sloe Hill Residential Care Home Limited DS0000037036.V377466.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 Sloe Hill Residential Care Home Limited DS0000037036.V377466.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): 1 & 3 standard 6 is not applicable to this home. People using the 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 come to live at Sloe Hill are given appropriate information to make an informed choice and can be assured that they have had their needs assessed prior to being admitted to the home. EVIDENCE: The manager has recently up dated the Statement of Purpose which can be found in the entrance to the home. This provides prospective residents with information about what care and support the home is able to provide. A copy Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 Page 10 can be requested by prospective residents to take away so they are able to browse the information in their own time. The examination of the care files of newly admitted residents showed us that assessments had been carried out, which gave them a base on which to write the care plans on the care and support needs people required. The manager needs to ensure that all assessments that are carried out are dated and signed by the author to provide a good audit trail and ownership. He assured us that a slight amendment will be made to the current assessment form to include this information, so that staff will then have a place to sign and date the forms. Sloe Hill Residential Care Home Limited DS0000037036.V377466.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 & 10 People using the 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 live at Sloe Hill can be assured that their care and support needs are written in their care plans and they are protected through policies and procedures in the administration and storage of medication. EVIDENCE: From the residents that we spoke to during the inspection, we chose four care plans to examine. Two of the care plans were of newly admitted residents, which showed that they had been assessed prior to admission to ensure their needs could be met by the staff at the home. From the initial assessment, care plans had been drawn up which gave staff some information about the care and support needs of the resident and how these are to be met. Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 Page 12 When a resident is admitted they have in the daily notes folder a form called the “four week settling period” staff are encouraged to complete this three times a day giving information about what the resident has been doing and what support and care the staff have provided. The forms showed that some day’s information had not been added and where staff had put information this read “all care provided”. A discussion took place with the manager stating that it would be beneficial if staff completed these in more detail so as to focus on what the residents are able to do for themselves thus making the care plans more person centred, and then providing staff with the information about what care and support the residents’ need from the staff. However, our discussions with the staff showed they were clear about the needs of the residents and what support they required and how they liked it to be done, although this information had not been provided in detail in the care plans. One of the newly admitted residents had had a fall prior to coming to the home, although a number of risk assessments were in place, the falls risk assessments had not been completed, the manager told us that he would address this following the inspection as a matter of priority. Other information contained within the care plans included a pen picture which gave a short history of the life of the resident, which is used when looking at activities they enjoy, not all of the files had this information as it had proved difficult at times to get the information from families. Whilst staff sit and chat with the residents they are able to listen to the residents and are able to get information about their past as they were able to tell us during the inspection about the residents past history, although this had not been recorded. Staff need to remember to record this useful information, as again this will help in the care planning process. We saw that the health needs of the residents are recorded within the care plans and staff ensure they record any visits and any action needed, including follow up appointments. The manager told us that they have a good relationship with the district nurses and are kept informed of progress on treatment of the residents, which staff then record in the care plans. A couple of the care plans we looked at the residents were diagnosed with diabetes, staff were aware of the diet that was required but the diet care plans did not provide detail on what foods they should avoid or reduce the intake of. It is recommended that information is provided to staff on diabetes to ensure they are clear of signs and symptoms they need to be aware of if the residents should become unwell. We saw that the care plans are reviewed on a monthly basis or sooner if required although they do not provide detailed information on how care and support needs have been met and usually state “no change” but they do give information on what has changed if required. Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 Page 13 Two medication trolleys have been purchased since the last inspection. This has increased the storage capacity and reduced the possibility of staff making errors in the administration of medication. The present storage room is compact and the temperature can rise above the recommended level, the manager in consultation with the builders are in the process creating a new storage space which is roomier and will help to keep the temperature at the required level and provide more storage. Examination of the medication storage, administration and disposal showed that it was all well managed as the seniors now carry out weekly audits and deal with any discrepancies through supervision. One resident who takes warfarin must have a risk assessment in place as they could be at risk of excessive bleeding if they were to have an accident. The senior staff member said this would be addressed immediately to ensure the resident is protected and all staff are made aware of the risk. Residents spoken to and told us that they were very happy with the care and support they received and felt they were treated with respect and dignity. Staff were seen to knock on bedroom doors and wait for a response before entering. Staff were seen to offer support in a caring and friendly way giving the residents time to stand and walk when getting to the table at lunchtime and supporting them to meet their personal needs. Sloe Hill Residential Care Home Limited DS0000037036.V377466.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 & 15 People using the 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 who live at Sloe Hill can be assured that they experience a stimulating environment which meets their needs and expectations. They are provided with an appealing and healthy diet which meets their needs. EVIDENCE: A full time activities co-ordinator is employed at the home and they have attended appropriate training for providing activities for older people. They provide activities throughout the week and these include games, manicures, and quizzes. Outings to the local shops, garden centres etc. are arranged and they use transport via “Helping Hands”, the manager also supports residents and a support worker by taking them into the town to do some shopping in his own Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 Page 15 car and then will collect them when they are ready to come home. The manager stated that he had appropriate insurance cover for carrying the residents and staff. The activities co-ordinator keeps a record of the activities people take part in, but does not reflect whether they enjoyed it, where somebody has chosen not to take part in an activity it is marked as “refused” it would be useful to ask the resident if there was a reason they didn’t want to join in and record this. This could highlight different activities that they may prefer to do or they may just not feel like doing what is on offer on that day. There are various places throughout the home where up and coming events are listed on A4 sheets of paper in blue ink, the activities co-ordinator may want to look at putting this into a pictorial format to make it easier for people to see what is happening. There are plans to bring an external drama group to the home where a small production is put on; they have had Dick Whittington and Mother Goose in the past. Movement & Music is held at the home and from those residents spoken to during the inspection stated they enjoyed this activity and felt it kept them moving. The staff are planning a Fireworks display, where families are invited to come along and join in the evening. Residents are able to choose whether to join in the activities or not and the activities co-ordinator will ask residents on admission about the interests and will try to incorporate these into the programme. Visitors are welcome at the home at any time and residents are supported to keep in contact with those they choose to, by assisting with telephone calls, writing letters etc. Residents are able to choose when they go to bed and when they rise, residents are supported to be as independent as possible and staff give them the time needed to achieve this for example allowing them time to move from one area of the home to another. Resident meeting are held on a regular basis and residents are able to discuss such things as activities, the menu, up and coming events. Minutes of the meetings were seen and these are available to the residents to see or even have a copy if they wish. The lunch time menu is written on the board in the dining areas and two choices are offered, the residents are asked in the morning for their choice for that day. If neither of the two choices are to their liking other alternatives are offered. Lunchtimes are able to be flexible to accommodate residents if requested. All residents spoken to were very pleased with the food with the Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 Page 16 exception of one who said “it’s not like my home cooking but its OK”. We joined the residents for lunch; the tables were laid nicely with cloths, mats and condiments. Residents were offered choice of drink to have with their meal, the meal served was hot, tasty and nicely presented. The meal time was pleasant, calm and a leisurely experience. After lunch residents are offered tea or coffee and they were able to choose where to sit, some chose to remain at the dining table, whilst others chose to move into the lounge chairs so they were able to watch the television. A small table was brought to them, in which to place their cup and saucer on. The cook keeps a full record of the food eaten by each resident and all appropriate temperature checks are carried out daily. All staff working in the kitchen has completed their food hygiene certificates. Whilst residents are offered drinks at set times they are able to ask for drinks at other times if they so wish. Snacks are available at any time on request Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 Page 17 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 & 18 People using the 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 live at Sloe Hill can be confident that there views will be listened to and acted upon appropriately. EVIDENCE: Policies are available to cover safeguarding, whistle blowing and complaints and staff state they are aware of these. Residents spoken to who feel they are able to say if they are unhappy about any aspect of the care and support and felt that they would be addressed appropriately. We have received no complaints in regard to the care and support that is provided at Sloe Hill Sloe Hill has introduced an advocacy scheme working with Age Concern who work with residents who have no or few relatives. The manager stated this is working well for the residents. Sloe Hill Residential Care Home Limited DS0000037036.V377466.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, 21 & 26 People using the 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 live at Sloe Hill can be assured that they live in a safe, well maintained, clean and pleasant environment. EVIDENCE: A tour of the home was conducted and it was found to be clean and well maintained. All bedrooms with the exception of one have all been provided with an ensuite toilet and sink. Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 Page 19 There are two assisted bathrooms within the home, a wet room has been provided which gives the residents choice about their bathing preferences. The upstairs floors, which had various levels has now been lifted to create one level so all residents are now able to access the lift and the bathing facilities even if they have some mobility problems. The company have provided a garden that is now secure by the installation of a new fence and gate. The external doors have been alarmed whilst this does not restrict the residents from accessing the garden, the alarm alerts staff to the fact somebody has gone into the garden and they are then able to check them if required at regular intervals. A new conservatory is being installed during October 2009, due to the existing one which is looking tired and in need of replacement. The company are putting in planning permission for an extension for a further twelve rooms which they hope will provide nursing care. Sloe Hill Residential Care Home Limited DS0000037036.V377466.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 & 30 People using the 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 live at Sloe Hill are protected through the robust recruitment practise in place and that the staff have the skills and are competent to carry out their roles. EVIDENCE: The residents spoken to during the inspection were very complimentary about the care and support that the staff provide and say “the staff very nice and can’t do enough for us” They no longer have to use agency staff although if the need arose they would use them as a last resort to meet the needs of the residents. They have a large number of staff who have worked at the home for a number of years which provides the residents with consistency and people who know them well. Call bells were seen to be answered promptly and the residents confirmed this is usually the case. Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 Page 21 All staff have completed level 2 in dementia care, they have also completed the following training over the last year, fire, safeguarding, infection control, care plans, challenging behaviour, first aid, care of the dying, medication, health and safety. The manager has the support of a training provider who helps look at the training for the coming year and helps in the planning of this. As a number of residents have diabetes it was suggested that an information session take place to ensure staff are clear in managing diabetes for those residents. A training matrix was available in the office detailing who has completed which training and what they may need to complete. Recruitment files of the newest members of staff were checked and they showed that all required information had been received prior to them starting their employment at Sloe Hill. This shows that all possible precautions had taken place to protect the residents. Sloe Hill Residential Care Home Limited DS0000037036.V377466.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 & 38 People using the 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 who live at Sloe Hill can be assured that the home is run in their best interests and that all that enter the home have their health, safety and welfare safeguarded and protected by procedures that are in place. EVIDENCE: The manager is a qualified nurse and has completed the NVQ 4 registered managers award; he maintains his skills and competence by attending training Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 Page 23 relevant to his role. The manager registered with us in July 2008. The residents’ told us that they felt that the home is run their best interests in mind and that he listens to them and acts upon any suggestions they may have, including choice of outings, menus and activities. The residents told us that they see him everyday he is working at the home and is always asking how things are going and they feel he listens to them. Staff stated that they are well supported by the manager and there is an open door policy and that they are able to address any concerns or make any comments, they will be listened to and acted upon appropriately. There is a quality assurance system in place to get the views of the residents, relatives and any other professionals who may visit the home to attend to the needs of the residents. This is conducted on a yearly basis and the results analysed and a report with any improvement for the coming years highlighted and an action plan drawn up. This is shared with the residents and relatives. The office records are well kept and securely stored in the office. The manager has updated all policies and procedures in the home in line with current practice or changes in legislation which promote the protection of the residents to ensure they live safely in a way that they choose. The manager ensures staff follow the policies and procedures of the home and they are able to access them easily. The individual supervision of staff would address any issues of training and practice and these are recorded and followed up as appropriate. Health and safety procedures are in place to protect the health, welfare and safety of all who live, work and visit Sloe Hill, a system of checks are carried out on a regular basis and record of these is made and any issues are addressed as required. The manager has arranged that all staff receive training in Deprivation of Liberty and the Mental Capacity Act. The manager is pro-active in trying to look at new ideas with the residents at the heart of them to make them enjoy their lives at Sloe Hill. Sloe Hill Residential Care Home Limited DS0000037036.V377466.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 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 4 X 4 X 3 X X 3 Sloe Hill Residential Care Home Limited DS0000037036.V377466.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 Sloe Hill Residential Care Home Limited DS0000037036.V377466.R01.S.doc Version 5.2 Page 26 Care Quality Commission Eastern Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: 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. 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