Care Home: The Cottage

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What the care home does well The home is managed and run in the best interests of the people who live there.The CottageDS0000000986.V376804.R01.S.docVersion 5.2The people who live at The Cottage said they are very happy and the home has a warm and welcoming atmosphere. People said they enjoy living there and said the staff do what people want in the way people prefer. One person said of the home that `If there`s anywhere better it must be heaven.` All the relatives we spoke with said they are very happy with the care the staff at The Cottage provide. The pre-admission assessments make sure the home can meet people’s needs. The staff understand the needs and preferences of all the people who live at the home. People’s health is looked after and the staff have the skills and experience they need to do this. One healthcare professional confirmed that the staff are knowledgeable about people`s care needs. The medicines administration procedures are safe. The records are accurate and confirm that people are receiving their medicines in the way their doctor has prescribed. Everyone said that staff listen to them, and act on what they say. Visitors said they are always welcomed. There is good and friendly interaction between the people who live at the home and the staff. There seemed to be enough staff on duty to make sure they have time to spend with people in conversation as well as supporting people to take part in individual and group activities. People said that they enjoy the meals and the food is of an excellent quality The home`s recruitment procedures are thorough, making sure that staff are safe to work with the people who live at the home. All the staff said they enjoy working at the home and felt they were well supported by the acting manager. They all said the training is good and helps them to do their job well. More than half of staff have achieved a National Vocational Qualification (NVQ) at level 2 or 3. The complaints and adult protection systems work well and people said they know and understand what to do if they have a concern. The home is clean and well maintained and everyone we spoke to said the home is always kept fresh and clean.The CottageDS0000000986.V376804.R01.S.docVersion 5.2Page 7 What has improved since the last inspection? The Statement of Purpose and Service Users’ Guide have been updated since the last inspection, to reflect the full range of services the home offers. The records showed that all of the staff have had adult protection training. Staff take this training to make sure they all understand fully how to protect the people who live at the home. Improvements are being made to the decor and furnishings within the building, including new armchairs in the lounges and new bedroom furniture and bedding. This will make the house a more attractive place for people to live. Automatic door closure guards, connected to the fire alarm system, have now been fitted to the doors in the hallway between the dining room and the lounge as part of the home’s fire safety measures. The records and the staff confirmed that all staff are now having one to one supervision meetings with their line manager. Supervision meetings support staff to plan their personal and professional development and give them the opportunity to discuss any areas of concern in a confidential setting. The home`s manager has applied for registration with us and this process is almost complete. What the care home could do better: If the person, or their relatives, are willing to disclose information about themselves a life history can give staff a basis for understanding the individual better and help them to provide more person centred care and plan activities they will enjoy. A wider range of activities and outings would be beneficial and make people`s daily lives more interesting and fulfilling.The CottageDS0000000986.V376804.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE The Cottage 1a Church Street Rastrick Brighouse West Yorkshire HD6 3NF Lead Inspector Liz Cuddington Key Unannounced Inspection 22nd July 2009 10:55 DS0000000986.V376804.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. The Cottage DS0000000986.V376804.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 The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Cottage Address 1a Church Street Rastrick Brighouse West Yorkshire HD6 3NF 01484 718808 None jennymoffat@btopenworld.com 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) Mrs Jennifer Moffat Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd July 2008 Brief Description of the Service: The Cottage is a converted property situated on the main road into Rastrick, coming from Huddersfield. Although the road can be busy during the day, it is quiet at night. Once inside the home, the traffic noise is minimal. The home is on a bus route and is close to local shops. The Cottage is a family owned home providing personal care and accommodation for nineteen men and women over the age of 65 years. The living accommodation is on two floors, with a stair lift linking the ground and first floors. There is a conservatory and patio to the rear of the property. The home has a small car park and there is parking on nearby streets. The Cottage DS0000000986.V376804.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 two stars – good service. This means the people who use this service experience good quality outcomes. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The weekly fees the home charges are between £347.50 for a shared room and £365.00 for a single room. The fees do not include personal expenses such as hairdressing and chiropody. The purpose of this inspection was to assess the quality of the care and support received by the people who live at The Cottage. The visit to the home was carried out over one day by one inspector. The last key inspection was in July 2008. The methods used to gather information included conversations with the people living at the home, their relatives, healthcare professionals and the staff, as well as looking at care plans and examining other records. We received the homes self-assessment questionnaire before the inspection visit. This gave us useful information about the home and helped us plan the visit. We would like to thank the people who live at the home, their relatives and the healthcare professionals, for their welcome and hospitality and for taking the time to talk and share their views during the visit. What the service does well: The home is managed and run in the best interests of the people who live there. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 6 The people who live at The Cottage said they are very happy and the home has a warm and welcoming atmosphere. People said they enjoy living there and said the staff do what people want in the way people prefer. One person said of the home that If theres anywhere better it must be heaven. All the relatives we spoke with said they are very happy with the care the staff at The Cottage provide. The pre-admission assessments make sure the home can meet people’s needs. The staff understand the needs and preferences of all the people who live at the home. People’s health is looked after and the staff have the skills and experience they need to do this. One healthcare professional confirmed that the staff are knowledgeable about peoples care needs. The medicines administration procedures are safe. The records are accurate and confirm that people are receiving their medicines in the way their doctor has prescribed. Everyone said that staff listen to them, and act on what they say. Visitors said they are always welcomed. There is good and friendly interaction between the people who live at the home and the staff. There seemed to be enough staff on duty to make sure they have time to spend with people in conversation as well as supporting people to take part in individual and group activities. People said that they enjoy the meals and the food is of an excellent quality The homes recruitment procedures are thorough, making sure that staff are safe to work with the people who live at the home. All the staff said they enjoy working at the home and felt they were well supported by the acting manager. They all said the training is good and helps them to do their job well. More than half of staff have achieved a National Vocational Qualification (NVQ) at level 2 or 3. The complaints and adult protection systems work well and people said they know and understand what to do if they have a concern. The home is clean and well maintained and everyone we spoke to said the home is always kept fresh and clean. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: If the person, or their relatives, are willing to disclose information about themselves a life history can give staff a basis for understanding the individual better and help them to provide more person centred care and plan activities they will enjoy. A wider range of activities and outings would be beneficial and make peoples daily lives more interesting and fulfilling. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 8 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. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 9 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 The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 10 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 does not apply 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 are assessed before they are admitted to the home, to make sure their needs can be met. EVIDENCE: People said that they were given enough information about the home before deciding to move in, and they had also received a contract. The Statement of Purpose and Service Users’ Guide have been updated since the last inspection. Where possible the home encourages people and their families to visit the home and talk to the people who already live at the home, their relatives and the staff. The home invites them to come and spend time at the home, share a The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 11 meal and maybe take part in the days activities. This means that the home can get to know the persons needs and the individual has the information he or she needs to make a decision. Before moving into The Cottage, peoples needs are assessed to make sure that the home is able to meet their needs. This assessment, as well as Social Services needs assessments when available, forms the basis for the individual plan of care and support. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 12 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. Peoples personal and healthcare needs are met. People are protected by the medication administration systems. Staff treat people with respect, care and consideration at all times. EVIDENCE: From observation and discussions with staff and people living at the home, it was clear that the staff are aware of each persons needs and preferences. The staff make sure they provide the help people need in the way they prefer. One healthcare professional said that the staff are knowledgeable about people’s care needs and are able to give them the information they need. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 13 Three care and support plans were looked at, to make sure that peoples health and personal care needs are being met in the way the person prefers. The plans cover each area of the individuals care needs. They all contain enough information to guide staff in how to care for and support each person. The plans include risk assessments and management plans where someone is at risk of falling, developing a pressure sore, becoming malnourished or any other area the staff feel may put the individual at any risk. Health care visits and treatments are recorded in detail and everyone who commented said they always receive the healthcare they need. The plans contain a lot of detailed information. This makes sure all the staff have records to refer to that are up to date and give them all the information they need in order to support each person. The plans include a social care assessment and the home have begun asking people and their relatives to complete a life history booklet. If the person, or their relatives, are willing to disclose information about themselves a life history can give staff a basis for understanding the individual better and help them to provide more person centred care. The care plans are reviewed regularly and show that, where possible, the individuals and their families are involved in developing and reviewing their plans. Calderdale Social Services’ carry out annual reviews, to make sure that people’s needs are being met at the home. The manager has started to ask the social workers to complete a review form, commenting on their views of the care and support the individual is receiving. One social worker wrote ‘Everything very satisfactory’ after one review visit. During the last year the home has started to offer respite care. At present these people’s care plans only include the home’s initial assessment of needs and Social Services’ assessment and care plan. To make sure that the plans for people who are there for respite accurately reflect their needs, the home should develop a suitable care plan, including the areas of care and support the person needs. These plans should be reviewed each time the person goes to The Cottage for a respite stay. The relatives we spoke with said they are satisfied with the care their relative receives and everyone who commented said they are looked after well. One person’s relative commented that the staff make an effort to help their relative The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 14 to choose the type of clothes and accessories they have always worn. One visiting healthcare professional also said that people are always well dressed and everyone looked to be wearing clothes they had chosen and were comfortable in. The medicines are kept safe and secure in a locked cabinet and the medicine trolley was locked when unattended. Most of the medicines are supplied by the pharmacy in a monitored dosage system, but some remain in the original packaging. The Medicines Administration Record (MAR) charts, which must show clearly the quantities of medicines received and in stock for each person, were examined. The medicines supplied in the monitored dosage system appeared to be recorded accurately. We checked some of the medicines that were supplied in their original packaging, to make sure the numbers that had been signed as administered tallied with the amounts received and the quantities remaining. The records showed that the medicines we looked at had been administered and recorded accurately. The controlled drugs register and stock was checked and was accurate. There is a refrigerator for storing medicines that need to be kept there and the temperature is checked daily, to make sure it is always correct. Boots’ pharmacy carries out regular medication audits, to confirm that medicines are being administered and recorded accurately. During the visit, all the staff were seen to treat people with respect and maintain their dignity. The people who commented said that they receive the care they need and are supported to maintain their independence for as long as they are able. Everyone said the staff listen and act on what they say. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 15 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to take part in a range of activities, although this could be developed further to offer people more variety and choice. People are offered a good choice of meals which are of an excellent standard, to make sure their dietary needs and preferences are met. EVIDENCE: The home’s staff plan and lead the activities and people take part or not as they wish. The staff spend time with people on one to one activities, as well as doing things people can enjoy together. These include armchair exercises and games such as dominoes and cards, watching films and singing. Every eight weeks someone from an organisation called ‘Active Minds’ comes in to lead an activity session and on alternate months a singer or other The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 16 entertainer visits the home. The staff spend a lot of time in conversation with people and having reminiscence discussions. Some people’s care plans include a life history. If the person, or their relatives, are willing to disclose information about themselves a life history can give staff a basis for understanding the individual better and help them to plan activities they will enjoy. Some people have said they enjoy gardening and this is to be included in the activities that are offered. Special days through the year are celebrated and relatives are invited to join in. The menus are planned by the chef to include the wishes of the people who live at the home and to meet any special dietary needs. There are always alternatives available if people do not want the choices on the menu. As well as a cooked meal at lunchtime, there is a choice of hot and cold dishes at teatime. People said that they enjoy the meals and the food is of an excellent quality and is always hot when it is served. Every morning the chef asks each person what they would like for their breakfast and prepares their meal individually. On the day we visited the main course at lunchtime was either gammon or Cornish pasties with vegetables, followed by either coconut jam sponge and custard or a milk pudding. People are offered hot and cold drinks and snacks throughout the day. The people who live at The Cottage said they can do what they want, when they want. This confirmed our observations that the staff support people to live their life in the way they choose. The Cottage DS0000000986.V376804.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 are aware of how to raise a concern or make a complaint if they are dissatisfied with the service. The staff have received suitable training and understand the adult protection policies and procedures, which makes sure that people at the home are safe. EVIDENCE: Any complaints or concerns are recorded in a complaints file. The actions taken and the outcomes are recorded. The responses to complaints answered the persons concerns thoroughly. Where they are needed, improvements are made as a result of complaints investigations. Staff said they know what to do if anyone has concerns. The people who live at the home said they know what to do if they have a concern or complaint. One relative said that they have never had cause to complain. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 18 Newly employed staff are made aware of the homes whistle blowing policies and procedures, to be used if they suspect abuse or see examples of poor practice. All the new staff take adult protection training as part of their induction training. The records showed that all of the staff have had adult protection training. Staff take this training to make sure they all understand fully how to protect the people who live at the home. All the appropriate policies and procedures are in place to guide staff. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 19 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, 20, 21, 25 & 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. The home provides a comfortable and well-maintained environment. EVIDENCE: The home is clean and generally well maintained and everyone we spoke to said the home is always kept fresh and clean. The rooms are comfortably furnished and have a welcoming feel. There are sufficient, accessible toilets and bathrooms on all floors of the house. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 20 Downstairs there are two lounges and a dining room; one of the lounges is a conservatory which has french windows leading onto a patio. A programme of refurbishment in the bedrooms and lounges has been started and this will make the whole home a more attractive place for people to live. When we visited, the owner and manager were asking people what material they would like for the new armchairs for both lounges. New furniture has been ordered for the bedrooms, along with new bedding. Most people are happy with this, but if someone is not then the home will respect the individual’s wishes to keep their own furniture. The downstairs bathroom has been refurbished and a new assisted bath has been fitted. The upstairs bathroom will be refurbished later this year. Protective gloves, aprons and disinfecting hand rub are available for staff to use when necessary, to support the homes infection control measures. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 21 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. Sufficient staff are employed to meet peoples needs. People are protected by thorough recruitment procedures, which ensure that staff are suitable to work with people who live at the home. Suitable training is provided to make sure staff have the skills and knowledge they require to be able to meet peoples needs. EVIDENCE: The staff rotas, and peoples comments, confirmed our observations that there are enough staff on duty to meet peoples care, social and leisure needs. In addition to the manager, there are usually two or three care staff on duty during the day and evening and two waking night staff. This number seems to be sufficient to provide care and support for the sixteen people who currently live at The Cottage. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 22 The staff confirmed that staffing levels are adjusted to meet peoples needs. People who live at the home said there are enough staff around and our observations confirmed this. The homes recruitment procedures are thorough, making sure that staff are safe to work with the people who live at the home. All new staff complete an application form and provide two written references. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks are obtained and no new staff begin work until these checks have been completed satisfactorily. There is plenty of training available for staff. All the staff said the training is good and keeps them up to date. The home keeps good records of staff training, which also shows when updates are needed. The staff have had food hygiene, moving and handling and medication training either early this year or at the end of last year. Training courses on infection control, fire safety, first aid, dementia care and other health and safety training are booked for later this year. The management are also scheduling training for staff on the implications of The Mental Capacity Act and deprivation of liberty for this year All new staff complete induction training which meets the Skills for Care criteria. This gives them good basic training to help them do their job effectively, and provides a sound basis for taking a National Vocational Qualification (NVQ) course. Seven of the thirteen care staff have achieved an NVQ in care at level 2 and three of them also have the level 3 award. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 23 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, 36, 37 & 38 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. The home is safe and well managed, in the best interests of the people who live there. EVIDENCE: The manager has the necessary experience and qualifications to manage the home, in the best interests of the people who live there. The manager attends training to keep up her professional development and has almost completed her registered managers’ qualification. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 24 Although there have been some delays, the manager has applied for registration with us and this process is almost completed. The records and the staff confirmed that all staff are now having one to one supervision meetings with their line manager. Supervision meetings support staff to plan their personal and professional development and give them the opportunity to discuss any areas of concern in a confidential setting. The staff said that they are well supported and they work well together as a team. Regular staff meetings are held and staff are encouraged to make their views known and contribute to the running of the home. Peoples personal information is stored securely when it is not being used. Where the home helps people to manage their personal finances, accurate records are kept of all transactions and all monies are securely stored. Regular audits are carried out by the homes management, to make sure everything is in order. The homes policies and procedures are kept up to date, to make sure they provide relevant information to guide staff on how to act in every situation. All the regular health and safety checks for the home are carried out in a timely manner. These measures make sure that the health, safety and welfare of the people at the home is promoted and safeguarded. The laundry is well run and peoples personal clothing, as well as their bedding and towels, are properly cared for. Following their most recent inspection, the Environmental Health Officer has awarded the homes kitchen a score of four stars out of a maximum of five, for hygiene and good kitchen practice. The requirements of their report have been dealt with. Automatic door closure guards, connected to the fire alarm system, have now been fitted to the doors in the hallway between the dining room and the lounge as part of the home’s fire safety measures. The home has a range of quality assurance systems in place, to help determine the quality of service the home offers. These include surveys for the people The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 25 who live at the home and their relatives, meetings for people who live at The Cottage, staff meetings and regular audit checks. We received the home’s annual self assessment form before the inspection. It contained brief information about the home and the service that is provided, but it needs to be more detailed in order to give us a fuller picture of the service and any improvements or difficulties they have had during the past year. The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 26 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X X 3 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 3 3 3 The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? 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. 1. Refer to Standard OP12 Good Practice Recommendations A life history of each person who lives at the home may be useful and would give staff a basis for understanding the individual better and help them to plan activities they will enjoy. A wider range of activities and outings would be beneficial and make peoples daily lives more interesting and fulfilling. 2. OP12 The Cottage DS0000000986.V376804.R01.S.doc Version 5.2 Page 28 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@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. 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