Care Home: The Old Hall Residential Care Home

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What the care home does well The home is a clean, safe and comfortable environment for the people who live there. There is a friendly interaction between staff and residents. People are satisfied with the standards of care and are treated with respect and dignity. The food is tasty and provides people with a balanced diet. Staff training is comprehensive and provides staff with the skills to care appropriately for the residents. What has improved since the last inspection? This is the first key inspection of this care home since it was bought by the current owners in November 2008, although it was already an established care home prior to the purchase. However, people told us that improvements have been made since the new owners took over and since the manager was registered by us. What the care home could do better: The activities provided must be in enough variety and reflect the needs, capabilities and preferences of the residents to enable and encourage them to participate and keep as fit and well as possible. There must be enough staff on duty at all times to enable the residents to have the attention they need to live as full a life as possible. The staffing levels need to be re-assessed to ensure that people are cared for safely and according to their wishes at all times. It should be noted that at a follow-up phone-call to the provider and manager shortly after our visit, they informed us that the staffing levels have now improved. People also told us that staff now have more time for them and staff confirmed that they are not so rushed in their work. We made two requirements at this inspection visit, which are located at the end of this report.The Old Hall Residential Care HomeDS0000072956.V375298.R01.S.docVersion 5.2 Key inspection report CARE HOMES FOR OLDER PEOPLE The Old Hall Residential Care Home Northorpe Road Holton Holgate Spilsby Lincolnshire PE23 5NZ Lead Inspector Vanessa Gent Key Unannounced Inspection 6th May 2009 11:20a DS0000072956.V375298.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 Old Hall Residential Care Home DS0000072956.V375298.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 Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Old Hall Residential Care Home Address Northorpe Road Holton Holgate Spilsby Lincolnshire PE23 5NZ 01790 753 503 01790 753 503 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) www.keshcare.co.uk Kesh-Care Limited Mrs Elizabeth Alice Lambert Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21), Physical disability (21) of places The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories 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 The maximum number of service users who can be accommodated is 21 4th April 2007 2. Date of last inspection Brief Description of the Service: The Old Hall is a privately-owned, two-storey care home providing personal care for up to twenty-one people of either sex over the age of 65 years and two people under 65 years of age. Two people in the category of Physical Disability can also be accommodated. This is the first inspection since the owners purchased the home. The home is in a Georgian country house with a ground floor extension, situated in the village of Halton Holegate, less than two miles from the historic market town of Spilsby, and ten miles from the seaside town of Skegness. The village has a church and a pub. The accommodation consists of nineteen single rooms, all but one of which have en-suite toilet and washbasin facilities, and two double rooms which are en-suite. Communally, there is one lounge, a smaller room designated as a library and one dining room. There are five large communal bathrooms, four with a toilet, available for those who need additional support with bathing. There is a passenger lift allowing access to the first floor. The home also has a therapeutic suite where hairdressing, chiropody and aromatherapy are on offer. Outside, the gardens are extensive, secluded and well-tended. There are outbuildings within the grounds that can be used for communal meetings and administration and ample space for car parking. The weekly fees charged are between £351 and £435. Extras such as The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 5 hairdressing, chiropody, therapies, personal newspapers and magazines are charged separately. Information about these charges, as well as the day-to-day running of the care home can be found in the statement of purpose and service user guide, provided by the manager to interested people and those already living in the home. The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two star – good service. This means the people who use this service experience good quality outcomes. An unannounced visit was made to the home as part of a key inspection. The people who live at the home expressed the wish that they be called ‘residents’. The manager completed and sent us a self-assessment form called the Annual Quality Assurance Assessment (AQAA), giving us information about the service, which contributed to the inspection process. Information from this, as well as that which we hold about the service was used to plan the visit and produce this report. The method of inspection we used during our visit is called ‘case-tracking’. This involves selecting a proportion of residents, and tracking the care they receive through the checking of records, discussion with them and the staff and observation of care practices. Our visit to the home focused on whether key standards and on how people feel about the quality of the service provided. The care received by four residents was followed in detail to ensure the health, safety and welfare needs were fully met and that they were supported to maintain their dignity, independence, autonomy and choice. We spoke with four staff members on duty. Residents including those being case-tracked told us of their experience of living at the home. We also talked with people who visit the home. We observed people’s care, and looked at personal records, general house records and staff records. All the residents and visitors we spoke with were positive about the level and quality of care given. They told us that staff always listen to what they say and that the food is liked. Any comments we received will be mentioned in the main body of this report. We made a partial tour of the home and looked at a sample of other records. The manager was present throughout the latter part of our visit. The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 7 What the service does well: The home is a clean, safe and comfortable environment for the people who live there. There is a friendly interaction between staff and residents. People are satisfied with the standards of care and are treated with respect and dignity. The food is tasty and provides people with a balanced diet. Staff training is comprehensive and provides staff with the skills to care appropriately for the residents. What has improved since the last inspection? What they could do better: The activities provided must be in enough variety and reflect the needs, capabilities and preferences of the residents to enable and encourage them to participate and keep as fit and well as possible. There must be enough staff on duty at all times to enable the residents to have the attention they need to live as full a life as possible. The staffing levels need to be re-assessed to ensure that people are cared for safely and according to their wishes at all times. It should be noted that at a follow-up phone-call to the provider and manager shortly after our visit, they informed us that the staffing levels have now improved. People also told us that staff now have more time for them and staff confirmed that they are not so rushed in their work. We made two requirements at this inspection visit, which are located at the end of this report. The Old Hall Residential Care Home DS0000072956.V375298.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 Old Hall Residential Care Home DS0000072956.V375298.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 Old Hall Residential Care Home DS0000072956.V375298.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 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 information about the home and how it runs is detailed enough to help people to decide if they want to move into the home. The assessment done for people who want to live at the home ensures that the manager and staff know they can meet people’s needs before they move in. EVIDENCE: The new statement of purpose and service user guide are up-to-date and detailed. The manager told is she is in the process of getting residents and staff involved in taking photographs and adding interesting information to the service user guide about what people’s lives are like at the home. The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 11 People told us that the manager visited them in their previous accommodation and asked them lots of questions before offering them a place. They knew that this was to make sure they could be cared for in the way they wanted and needed. Pre-admission assessments we saw in people’s care plans confirmed this. The manager told us they are not contracted for and do not provide an intermediate care service. The Old Hall Residential Care Home DS0000072956.V375298.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. Residents’ needs are met by clear care plans, regular liaison with other healthcare professionals and safe medication practices, and they are cared for with dignity. EVIDENCE: The care plans we saw of people whose care we followed were comprehensive, clear to read, set out in sequence and showed the involvement of each individual concerned. At our last review of the service, people told us, “They try to keep us involved with our care plans and with what’s going on”. A resident said this was still the case. The manager told us, in her self assessment, that they encourage people to take part in producing and reviewing their care plans and to sign to show they The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 13 have understood what their care plans are for and about. We saw people’s signatures in some of the care plans we looked at. A healthcare professional who visits the home frequently told us that they were in regular contact with the staff and manager. They did not identify any problems and said that staff contact them without delay if a person is poorly or if they need advice. They said, “It’s a lot better than it was a year ago. There’s good communication now; they will always phone for help or to call the doctor in; they listen to advice and always ask questions. They’re good at caring for people’s wounds and catheters and personal hygiene care. I observe that they always do the moving and handling correctly.” All the residents needed help in order to take their medicines in a safe way. Each person’s medication chart was completed fully and clearly and had a photograph and details about that person so staff members could easily identify them. The supplying chemist did three monthly audit visits to assist the staff to maintain safe and effective practices. Their latest reports indicated that they had no issues with the staffs’ medication practices. Staff told us they do not give out medicines unless they have received the appropriate training. Residents said they were treated with dignity and respect, that they were listened to and that things they wanted were acted upon. Relatives said the staff were very friendly and that “things are better now.” “I’ve got only praise for the manager and staff. Whereas before, for quite a while, there was sometimes no laundry done, no cleaning, people weren’t getting showered or bathed enough and sometimes there was no chef on duty. But it’s much better now, except sometimes, like today, when [my relative] had to wait fifteen minutes for attention because they are short-staffed.” A person told us, “They’re getting it right now.” The Old Hall Residential Care Home DS0000072956.V375298.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents do not have enough variety or quantity of activities but in all other aspects of living at the home, they are able to make their own choices about how they want to live their lives, and what they want to do. They have a healthy, appetising, varied diet that is meets their needs and preferences. EVIDENCE: People told us that they do not have as many activities provided as they had before but they believe that is because “there are often not enough staff on duty at the moment. So there’s not enough time to do extra things. But they look after us and are very caring.” “We used to have arts and crafts but not now. We used to have newspapers provided but now we have to pay for our own.” We were shown a chart which had activities listed for one session only on Mondays and Fridays. Several residents told us they would like to have more activities. They told us they used to have regular residents’ meetings but there are not so many now. The manager told us they had residents’ meeting The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 15 two to three weeks before and that she is intending to instigate them regularly. In her self assessment, she said, “We are going to introduce an activities coordinator; this will enable the residents to have a better choice. In the last 12 months, we have introduced ‘My Life History Book’ which residents can use in their reminiscence sessions.” She said that they also intend to become members of the charity N.A.P.A (National Association for the Provision of Activities) to help them improve the activity provision at the home. Visitors who came to the home during our visit told us they were always made welcome by the staff. They said “I only have praise for the staff. They’re so caring and lovely. Even though they are sometimes short-staffed, they usually come to [my relative] quickly when she needs help.” The manager told us, in her self assessment, that they have “introduced more outside activities”. At the last inspection visit, it was noted that “the home operates very much as part of the local community and invites neighbours to join in local activities”. People said that these are in place at the moment. The manager said they have a lot of visitors who come to see the people who live there. This was confirmed by the names written in the visitors’ book. People told us they can always choose what they want to do and that they are given full autonomy in their lives. People told us that “the food is excellent; there’s plenty of choice and it’s all fresh cooked. They give us plenty of vegetables, and they make homemade cakes and puddings which are lovely”. The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 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. Residents are protected by knowing they can always voice any concerns and will be taken notice of, and by staff who are trained to prevent abuse and who are conscientious and caring to the residents at all times. EVIDENCE: Neither the manager nor we had received any complaints since the new owners took over. People told us they are satisfied with the care the staff provide. “They are very caring and lovely. They look after us well.” “I’m happy here – they’re very good.” People told us they know how to make a complaint but one person said, “They deal with anything straight away but there’s nothing really I’ve been unhappy with”. Previously, a visitor said, “If I wasn’t happy about something, I’m sure the manager would sort it out straight away but things are fine”. Staff told us, and the manager and their records confirmed that they have had training to safeguard the residents. They knew what to do should someone make an allegation. They said they work well together but would not hesitate The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 17 to mention any bad practice they observed in a colleague. “We all work as a close team and have confidence in each other”. Residents said that they felt safe and well-cared for at the home. A visitor said, “The staff are compassionate to the residents, especially if anyone is poorly and in bed all the time”. The Old Hall Residential Care Home DS0000072956.V375298.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, 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 manager ensures that the people live in a comfortable, clean, wellmaintained environment to ensure they are cared for safely and feel ‘at home’. EVIDENCE: People told us they were satisfied with the cleanliness of the home and their rooms. A visitor said that the rooms were tidier and cleaner than they had been before the new owners took over. Whilst looking around the home and at the rooms of the people we were case-tracking, we saw that everywhere was clean and tidy. It was confirmed by the residents and a visitor that this is always the case. Some residents who have lived at the home for many years The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 19 told us that although things change often, they are happy living there and wouldn’t want to live anywhere else. Risk assessments were in place for health and safety measures in the home, as confirmed in the manager’s assessment form. The last Environmental Health Officer’s report was positive in its feedback. There were no issues to address. The last fire safety check was done in August 2008, before the new owners took over. The issues raised were addressed by the manager and maintenance team to ensure people were safe. Records showed that the maintenance person made checks and kept records to ensure hygiene is safely maintained in the home. We saw that potentially hazardous substances were stored appropriately in locked cupboards. In the laundry, staff told us that a new washing machine had been installed but that the tumble dryer had not worked for two weeks. They said that the machines were domestic in quality and size and could not always deal with the large loads of washing and drying they had to do. The staff said they were satisfied with the systems in place to maintain a safe environment and with the awareness training they received on this subject. We were told, and saw in the home’s records, that systems were in place to minimise risks of infection through water outlets, water temperature valves are fitted to water outlets for which testing records were maintained and all equipment in the home is tested regularly to ensure it is safe to use. The Old Hall Residential Care Home DS0000072956.V375298.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): Standards 27, 28, 29, 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. At the visit there were not enough staff on duty to enable the residents to have the attention they needed to live as full a life as possible and to ensure that people were cared for safely and according to their wishes at all times. Residents are in safe hands with well-trained and caring staff to ensure their comfort and well-being is maintained. EVIDENCE: When we arrived for our visit to the home at 11:20 am, there were two members of staff on duty and they were behind with their duties of getting people up, giving breakfast and morning medications and attending to the laundry. The staff were rushing around. People said they were waiting a long time for attention that morning. Neither of the staff had enough time to spend time with us as we undertook the inspection visit. The person in charge had not been at work for three weeks, but did not have the time to fully acquaint herself with the changes that had taken place in her absence. The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 21 A resident told us, “There’s not enough staff at the moment so there’s not enough time to do extra things for us. But they do look after us and are very caring.” Once the manager returned in the afternoon, we saw and were told that there were enough staff to care safely and sufficiently for the residents in their care, although this did not include spending time doing any activities with them. It should be noted that at a follow-up phone-call to the provider and manager shortly after our visit, we were assured that the staffing levels have now improved. People told us that staff now have more time for them and staff confirmed that they are not so rushed in their work. Staff told us that the recruitment process is safe, although we were not able to speak with new staff who had been recruited since the new owners took over. We saw that the staff files contained the information required to keep people safe. Staff told us that all but one of the staff members have got or are doing nationally-recognised qualifications that will help them do their job better and more confidently and care more knowledgeably for the residents. The records of a recently-recruited staff member showed that staff had been recruited and employed using recognised checks to ensure the safe care of the residents. One staff told us that the induction period is long enough to enable new staff to care safely and capably for the residents. They told us they also shadow an experienced staff member until they feel confident. We saw in their records that induction lasts for up to twelve weeks and the ‘Skills for Care’ programme is followed. Staff said they had done lots of the basic training in their nationally-recognised courses. Staff told us that they had received some training from the previous provider and were knowledgeable in caring safely for the residents but now needed update training, and to incorporate ‘extra’ courses that would enable them to care more efficiently for the residents. Staff told us the “the training is getting better. It is more supportive now.” The manager told us, in her self assessment, that she is planning to update all the staff training needs during the coming twelve months. Staff records contained certificates that they had gained through their studies. The manager plans to keep an audit of staff training to make sure everyone is up-to-date. The Old Hall Residential Care Home DS0000072956.V375298.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, 32, 33, 35, 36, 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 run in the interests of the residents and staff. Residents feel safe, happy and enjoy living at the home. Staff are happy in their jobs and feel supported by the manager. EVIDENCE: The manager has “come through the caring process”, has completed a nationally-recognised top qualification in care and is about to start her Registered Manager’s Award. She was registered as the manager by us in The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 23 November 2008. Staff say she is “caring, understanding and down-to-earth; you can talk to her about anything.” According to the staff duty rotas we saw at the time of our visit, and to what staff told us, the manager was counted as one of the caring staff, sometimes with only a total of two people on duty. This meant that she had no time to concentrate on her managerial duties, paperwork, liaising with other people, staff supervisions, monitoring and finding ways to improve the service they provide. One visitor said she did not often see the manager when she visited and some residents said she always talked with them but she did not always go in their rooms to chat because she was so busy. To gain the views and preferences of the people who live at the home, the manager distributes annual questionnaires for residents, relatives, visitors, staff and healthcare professionals. These she plans to analyse to see how she and the staff can improve the service provided. She told us that she holds regular resident and relative meetings, although she said these are not always well-attended. People told us she listens to them and they can talk with her about any concerns they may have. The manager said she wants to make sure that people are fully involved in providing regular feedback on how well the service is doing. We were told that the owner visits the home several times each week. At the time of our visit, the provider did not analyse or monitor the service in a formal manner, although the manager said he is always very aware of any issues. Most people or their relatives or representatives had chosen to look after their own finances. For those whose personal allowances are maintained by the manager, there are receipts and clear records kept. Staff confirmed they have now started to have one-to-one, supervision meetings with the manager, but the calendar showed, and they confirmed, that they have only had one session so far since she became the manager. Staff said they talk with her whilst they work but would feel better supported by more regular meetings. Records of their meetings are kept in their staff records. Staff have team meetings, which are documented. The manager says they are not held as often as she would like but intends that they will become more frequent to support staff fully. We saw that the records for electrical, water and equipment testing and management, fire drills and fire alarm testing and food management are upto-date. These and the records kept by the manager and maintenance man show that they are comprehensive enough to enable the home to be run safely and in accordance with the residents’ needs and wishes. The Old Hall Residential Care Home DS0000072956.V375298.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 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 2 X 3 The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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. 1 Standard OP12 Regulation 16(2)(n) Requirement There must be enough variety and quantity of activities that reflect the needs, capabilities and preferences of the residents, to enable and encourage them to participate and keep as fit and well as possible. There must be a sufficient number and skill mix of staff on duty at all times, to keep the people safe and care for their health and welfare. Timescale for action 06/09/09 2 OP27 18(1)(a) 09/05/09 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 OP33 Good Practice Recommendations It is recommended that the formal, documented supervision of staff should take place up to six times a year. The Old Hall Residential Care Home DS0000072956.V375298.R01.S.doc Version 5.2 Page 26 Care Quality Commission East Midlands Region Citygate Gallowgate Tyne and Wear NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.eastmidlands@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. 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