Care Home: St George`s Witham Nursing Home

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What the care home does well People living in the home receive a high standard of care that is delivered in an individual, person centred manner. Health and personal care needs are well met. The wishes and preferences of individuals are taken into account and their opinions are valued. People living in the home and their relatives express a high level of satisfaction with the service. People are cared for by a stable, competent staff team who have the skills, knowledge and training necessary to provide a good standard of care. A robust recruitment process ensures appropriate staff are employed. The home has a well structured management team, each with clearly defined roles and responsibilities. The management team demonstrate a commitment to providing a high quality service that continues to improve. What has improved since the last inspection? The service continues to improve record-keeping, in particular they have developed care plans that are more person centred. There have been significant improvements to the environment since the last inspection; the completion of the extension and building work has provided better facilities such as improved bathrooms and pleasantly landscaped gardens that people living in the home are able to access. What the care home could do better: The home should continue to identify areas for ongoing improvement through their systems of self audit and quality assurance. Key inspection report Care homes for older people Name: Address: St George`s Witham Nursing Home 18 - 20 Avenue Road Witham Essex CM8 2DT     The quality rating for this care home is:   three star excellent 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: Ray Finney     Date: 0 6 0 4 2 0 1 0 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 26 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: St George`s Witham Nursing Home 18 - 20 Avenue Road Witham Essex CM8 2DT 01376512258 01376502790 witham@stgeorgescare.com www.stgeorgescare.com Newton Chinneck Limited Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Amanda Keen Type of registration: Number of places registered: care home 40 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 physical disability Additional conditions: The maximum number of service users who can be accommodated is 40 The registered person may provide the following categories of service: Care Home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Physical Disability - Code PD Date of last inspection Brief description of the care home St Georges Nursing Home is registered to provide nursing care to adults over the age of 50 years with a physical illness or disability. The home can also take people over the age of 18 who require palliative care. The home is situated in a quiet avenue within walking distance of Witham town centre and local facilities, including the train station. Car parking is available at the home. The home has a courtyard garden with wheelchair access and gardens to the rear. A Service User Guide and Statement of Purpose with information about the service are available and can be obtained by Care Homes for Older People Page 4 of 26 Over 65 0 40 Brief description of the care home contacting the home. The home charges between £453.11 and £877.80 a week for the service they provide. Care Homes for Older People Page 5 of 26 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: three star excellent 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: A range of evidence was looked at when compiling this report. An unannounced visit to the home took place on 6 April 2010. We were given every assistance throughout the inspection by the deputy matron, other members of the management team, staff and administrators. The visit included a tour of the home. The manager completed an Annual Quality Assurance Assessment with information about the service they provide. Throughout the report this document will be referred to as the AQAA. Documentary evidence was examined such as staff rotas, policies and procedures, care plans and personnel records. Completed surveys were received from people living in the home or their representatives and from some members of staff. Some of the comments from the surveys are recorded throughout the report. Care Homes for Older People Page 6 of 26 What the care home does well: What has improved since the last inspection? What they could do better: 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 7 of 26 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 8 of 26 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 choosing to live at St Georges can be confident they will be able to make an informed choice based on the information the service provides and their needs will be assessed. Evidence: The service stated in their AQAA, we have a residents information pack in each room which explains the services we offer, i.e. telephones, broadband, Internet cafe. The pack also contains menu samples and our Complaints Procedure and residents and their families are made aware of the services we offer through our Statement of Purpose, including costs involved. This enables them to make an informed choice as to whether they come to live in our home. Since the last inspection the Service User Guide and Statement of Purpose have been updated to reflect changes in the home. The Statement of Purpose is freely available in the entrance foyer. On the day of the inspection staff in the office were in the Care Homes for Older People Page 9 of 26 Evidence: process of updating and developing the homes brochure using new photographs. The service stated in their AQAA, we have an excellent pre-admission procedure including a comprehensive pre-assessment for all potential residents to ensure that we can meet their needs. Our Matron or her Deputy undertake these assessments personally and we have a dedicated member of staff to carry out each admission to ensure that each resident is settled into the home properly and they can also discuss their wishes and needs which are then documented. The AQAA tells us about improvements to the assessment process in the last 12 months, our pre-admission assessment now includes a new form that must be completed to assess whether or not a deprivation of liberty is likely to occur and whether a resident has capacity to make their own decisions and plans for improvement include, continue to improve and build our documentation on Mental Capacity Act and Deprivation of Liberty. We discussed the assessment process with the deputy matron. The process is comprehensive and covers a range of areas including the category of care provided, prescribed medication, the persons present situation, communication, special equipment required, washing dressing and oral hygiene, hearing and sight, mobility, history of falls, eating and drinking, continence, skin integrity, foot care, sleep pattern, pain status and family involvement. There is also a mental capacity assessment in place and a full assessment of the persons nursing needs. There is a full range of risk assessments in place including skin assessment on admission and/or following hospital admission, which includes a body chart to map any areas where there may be skin breakdown. Each person has a Waterlow risk assessment which looks at skin integrity and what risks there are for the person around skin breakdown. Each person has a risk assessment around nutrition using MUST (malnutrition universal screening tool). Other assessments in place include moving and handling, risk of falls, a bedridden assessment, a continence assessment, and a risk assessment relating to the MRSA infection. Care Homes for Older People Page 10 of 26 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 using the service can be confident their personal and healthcare needs will be identified and they will be provided with the support to ensure these needs are met as they would wish. Evidence: The manager told us in the AQAA, We maintain high standards of health and personal care through our dedicated and highly trained staff team. We treat everyone as an individual, producing comprehensive person-centred care plans and we are able to access outside agencies when required. Our care plans are regularly updated to ensure that we continue to meet our residents needs and wishes. The information gathered through the assessment process is used to develop holistic care plans. The first part of the care plan (part A) asks the person a number of questions relating to their individual preferences and wishes. For example, the personal hygiene care plan asks do you wear make up?, how often do you like to wash your hair? and about clothes preferences. Questions relating to diet and fluids include where do you like to eat your meals?. One person had responded to this Care Homes for Older People Page 11 of 26 Evidence: question, breakfast in bed, the lounge for lunch and tea. The second section of the care plan (part B) identifies the level of assistance required and gives details of the actions needed to provide the necessary care. We examined the care plans for four people on the day of the inspection. There are a range of core care plans in place covering personal hygiene, diet and fluids, mobility, continence, night-time needs, social care and spiritual care. In addition there are also individual care plans relating to any specific condition or need such as management of pain or behaviour. The manager told us in the AQAA, we have good working relationships with a multidisciplinary team and we are constantly updating our policies to reflect the latest nursing procedures. We have strong links with the Macmillan nurses and the local hospices to ensure expert advice is at hand for our palliative care residents. Records examined contained a full range of documentation relating to peoples health care. There were charts for monitoring blood pressure, weight and peoples optical or dental needs. We also examined records of chiropodist visits, multidisciplinary team visits, doctors visits, outpatient appointments and records of medical investigations. Through discussions the deputy manager explained that they were in the process of changing to a new system for medication. The home is introducing a monitored dose system (MDS). On the day of the inspection the pharmacy provider was delivering training for staff on how to use the new system and how to record appropriately. We observed that staff interacted well during the training session, asking relevant questions, contributing to discussions and asking for clarification where necessary. The home also has a policy around self-medication and anyone wishing to take control of their own medication will be supported to do so where possible. We observed very good interactions between staff and people living in the home. Staff were noted to be polite and courteous. The deputy matron explained that they place a high value on courtesy and respect and as it is such an important part of the culture of the home all staff have this impressed on them at induction. In surveys received from people using the service and their relatives, positive comments were made about the care. One person said their relative, has been very well looked after and its a lovely clean place and staff are very helpful and friendly. Someone living in the home told us, they care for me very well. A member of staff said that what the home does well is, giving good quality care and make the residents feel at home. A member of staff who completed a survey told us, our home promotes independence Care Homes for Older People Page 12 of 26 Evidence: and individual care. Care Homes for Older People Page 13 of 26 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. People living in the home can expect to enjoy a lifestyle that meets their wishes, needs and interests. Evidence: The manager told us in the AQAA, we have a dedicated activities co-ordinator who works in the home five afternoons per week, who provides a varied programme of activities to suit the type of residents in the home at any one time and we have a residents information pack situated next to each bed. This includes a monthly activities programme, a sample of our menus and how to find out general information i.e. telephones, broadband connection etc. The deputy matron explained that they are in the process of developing a new system of recording in care plans. The section of the care plans relating to peoples activities starts with a life history containing information about the persons jobs, hobbies, pets and what the person enjoys socially. There is a Social and Occupation Assessment asking the person what activities they like to do. In one of the files examined, for example, there was a form entitled Aims and Objectives of Activity which describes the planned activity, the aim of the session and the purpose of the activity and explains why it is important to the individual. Staff complete a daily activity log to Care Homes for Older People Page 14 of 26 Evidence: record what the person has done during the day. The manager told us in the AQAA, we often have outside entertainers in the home. We have arrangements in place with local vicars and priests that visit the home on a regular basis. We discuss spiritual needs and beliefs with our residents so that they can be incorporated into their care and we display photos of activities and events on noticeboards within public areas in the home. A member of staff who completed a survey told us that what the home could do better is, provide more activities, but I know this is already being looked into. There is an activities programme posted on the noticeboard; activities taking place during the month include games such as target beanbag, name that tune, cards and dominoes, word games, general knowledge quizzes, bingo, DVD afternoons, board games and Scrabble challenge. Other individual activities are also available including one-to-one coffee and chats, hairdresser and manicures. The home also has entertainers include singers and music. People can take part in a Churches Together service every month. The manager explained in the AQAA that they have introduced an Internet cafe for the residents to use and have purchased a laptop computer from those residents who are bedbound. The manager said, this helps residents to keep in contact with friends and family. The manager further told us in the AQAA, we are constantly reviewing our menus to ensure that residents are given a varied choice of food. We strive to ensure that meals are presented in an attractive manner. Our soft diets are also catered for and presented in an equally attractive way. We examined menus, which showed that there is a good range of nutritious traditional foods available such as pork casserole or roast chicken. We observed on the day of the inspection that meals are individually plated up and taken on a tray to the resident wherever they have chosen to have their meal. Some people choose to eat in their rooms and others choose to eat in the lounge. On the day of the inspection there was a choice of sweet-and-sour chicken or a casserole with fresh vegetables. One person was having lunch with their family; the deputy matron explained that they try to encourage visitors to eat with relatives in a social setting. Care Homes for Older People Page 15 of 26 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service can be confident that their concerns about how they are treated are listened to and acted upon and they will be kept safe. Evidence: The manager told us in the AQAA, our Complaints Procedure is in the Residents Information Pack which is located next to each bed in the home and senior management are easily accessible and take any complaints very seriously. Complaints are acted on promptly and efficiently. As reported at the last inspection the home continues to have an appropriate complaints process in place. Any concern or complaint is recorded appropriately together with any actions taken to resolve the difficulty. Since the last inspection there had been no major complaints but any minor concerns have been documented together with how the concern was resolved. Any accidents or other incidents are appropriately recorded. As part of their Quality Assurance process the home sends out surveys to relatives and people living in the home. People who responded to the surveys confirmed that they know how to make a complaint should the need arise. The manager told us in the AQAA one of the things they could do better is, we need to look at the option of making information available in larger print for residents that Care Homes for Older People Page 16 of 26 Evidence: have poor sight. This would make the information more easily available for people with poor sight and consideration could be given as to how the information can be made available for people with more severe impairments, such as spoken word format. The manager told us in the AQAA, we have a thorough staff training on abuse and a comprehensive policy and procedure for the protection of vulnerable adults. As previously reported the service continues to have up-to-date policies and procedures around safeguarding (previously referred to as protection of vulnerable adults or POVA). Personnel records examined confirm that prospective employees are appropriately vetted, including a CRB (Criminal Records Bureau) disclosure. The staff training matrix confirms that all staff have a CRB check and all staff have received training around safeguarding. Our observations on the day of the inspection confirmed that staff listen to people and treat them with courtesy and respect. Care Homes for Older People Page 17 of 26 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. People can enjoy living in an environment that suits their lifestyle and which is comfortable, well maintained and clean. Evidence: The manager told us in the AQAA, we have a high standard of decoration in all our rooms with new furnishings and carpets. Our residents are encouraged to bring appropriate pieces of furniture with them to ensure a familiar and homely feel is maintained. Since the last inspection the new extension has been completed, which has considerably improved the environment. The home is spacious, bright and airy with comfortable communal lounges. Throughout the home furnishings are of good quality and are well maintained; the home is decorated to a good standard. The manager told us in the AQAA, we carry out frequent quality assurance checks on room cleanliness and general health and safety. Our household team work hard to maintain a good standard of cleanliness throughout the home. We often receive comments from visitors saying that our home always smells fresh. On a tour of the premises we noted that there was a good standard of cleaning and there were no unpleasant odours throughout the home. Care Homes for Older People Page 18 of 26 Evidence: The manager told us in the AQAA, we now have two beautiful gardens that incorporate decking for residents and are accessible via patio doors from groundfloor rooms. This will allow the residents to interact with each other or to sit quietly in the garden and we are keen to encourage residents to use our newly landscaped gardens and to get involved with growing vegetables and flowers for the home. Bathrooms and toilets contained appropriate adaptations to help people with limited mobility. Peoples individual bedrooms contain ample evidence of personal possessions such as pictures, photographs, ornaments and memorabilia. A relative who completed a survey as part of the homes quality assurance process commented, the home is clean and the staff are very kind and friendly. A relative who sent us a completed a survey said, the home is always presentable, well maintained and kept clean. Care Homes for Older People Page 19 of 26 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in the home can be confident they are cared for by a competent, appropriately skilled and trained staff team who can meet their needs. Evidence: The manager told us in the AQAA, we continue to maintain high staffing levels. Our team are a well-trained and highly motivated group who take pride in the work they do and are committed to maintaining high standards within a warm and homely environment. At the time of the last inspection we reported that the provider was committed to ensuring they have a well-trained and well supervised staff team in sufficient numbers to meet the needs of people living in the home. Through discussions the deputy matron demonstrated that this continues to be a high-priority in the home. We observed on the day the inspection that staffing levels were appropriate for the number of people in the home and peoples needs were being attended to promptly and efficiently. People who completed surveys as part of the homes quality assurance process were complimentary about the staff team. One person said, staff have a positive attitude and another said every single staff member is helpful and courteous. Care Homes for Older People Page 20 of 26 Evidence: The manager told us in the AQAA, we have several of our own NVQ assessors within the home who take carers through both level II and level III NVQ. The homes training matrix confirmed that a good percentage of staff have completed an NVQ (National Vocational Qualification) award or are in the process of doing the award. The manager further told us in the AQAA, we have rigorous recruitment checks and paperwork. We examined a sample of personnel records, which were well organised and contained all the documentation required by regulation including relevant references, proofs of identity and appropriate checks that the person is suitable to work with vulnerable people including CRB (Criminal Record Bureau) and POVA first checks. The manager told us in the AQAA, we have a Director of Training and Development who ensures all training needs are met and provides training opportunities beyond the statutory requirements. We have a dedicated Training Facilitator who ensures that all new staff not only complete their Skills for Care induction, but also our own home induction. This ensures that they are trained in the more practical aspects of care. Records examined confirm that the service has a staff training and development programme in place. The training matrix shows that staff have a Skills for Care induction, a home induction and basic training around personal care and promoting continence. Other training that staff receive includes moving and handling, infectioncontrol, fire safety, health and safety/COSHH (Control of Substances Hazardous to Health), eating and drinking, first aid, food hygiene, palliative care, continence promotion and incontinence management, pressure care, awareness of dementia and managing behaviours that challenge. Registered nurses employed by the home also have additional training relating to their role such as blood glucose monitoring, resuscitation, care planning, medicines and pharmaceutical training, supervision and appraisals. Staff who completed surveys made positive comments about the training they receive. One person told us they have, excellent internal and external training as relevant to position and someone else said, a lot of training is provided to all staff and extra training in any areas needed will be given. Care Homes for Older People Page 21 of 26 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living in St Georges can be assured the service is well managed in their best interests. Evidence: The manager told us in the AQAA, we have an experienced team of Directors who are available for advice and an excellent management team. Our matron has excellent communication skills and provides the motivation and leadership required for our home. The management team has methods of working that are open and transparent; management is very accessible and operates an open door policy. On the day of the inspection the deputy matron explained the management structure of the home. There is a new matron, the deputy matron, qualified staff and carers. One of the qualified staff has responsibility for training and induction of carers, manual handling and mentoring student nurses. This member of staff was able to demonstrate a good awareness of his role and professional responsibilities and also demonstrated a commitment to working to a high standard. It was evident from discussions with the Care Homes for Older People Page 22 of 26 Evidence: deputy matron that staff work well as a team, each with responsibilities in a specific area. The manager further told us in the AQAA, we have developed a good Quality Assurance system which helps us to maintain, audit and develop standards in all areas of the home. We monitor health and safety through Quality Assurance. Risk assessments and audits are carried out routinely. Any actions are dealt with quickly and efficiently. As previously reported the service has developed a robust Quality Assurance process. A range of audits are carried out to identify areas for improvement. Areas audited on a monthly basis include care plans, a review of medications, policies and procedures, fire processes, infection-control and a monthly review of meals. The deputy matron explained that, as a result of their audit processes, they had decided to change the medication system to make it more robust. A recent activity audit was carried out and as a result an action plan has been put in place to improve the social needs of people living in the home. As part of the quality assurance process surveys are sent out twice a year to relatives and to those people living in the home who wish to complete a survey and who are able to do so. We noted that many positive comments were recorded in these surveys, including no need to do anything more than you already do and I am so grateful for the way my [relative] is cared for at St Georges. You keep me really well informed about my [relatives]condition and are a constant source of comfort. The manager told us in the AQAA that one of the ways they are going to continue to develop and improve the Quality Assurance system is to, involve residents and relatives, where possible, in the general running of the home by arranging group meetings to discuss ideas on how to improve our services. A relative who completed a survey told us, communication through the office is very good and there is always someone to talk to. Lovely home. Staff who completed surveys were complimentary about the way they are supported. One staff member told us what the home does well is, support staff from day one, regular meetings to discuss progress and needs. The comments include, our home works well as a team and all teams co-operate and work together. These comments confirm that people using the service are confident that the home is run in their best interests. Care Homes for Older People Page 23 of 26 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 24 of 26 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 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 25 of 26 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 26 of 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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