Care Home: The Willow

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What the care home does well Before agreeing admission the home carefully considers the needs for each person and its capacity to meet their diverse needs. Prospective people to use the service and their families are encouraged to visit the home and get a feel of the home. The home ensures that people`s personal and health care needs are met in a manner that protects and promotes their privacy and dignity. People using the service, relatives and staff were confident that the home was providing an excellent standard of care. The following comments were noted from a health care professional respondent: "The staff are caring, considerate and respect residents` dignity." The home provides activities to enable people using the service to enjoy a full and stimulating lifestyle with a variety of options to choose from. The home is clean, safe, comfortable and fitted with the appropriate aids and adaptation to promote independence. The home ensures that staff are provided with the appropriate training to meet people using the service diverse needs and to ensure that the home`s aims and objectives are adequately met. The home is managed by an experienced manager. There are systems in place to ensure that it is run in the best interests of people using the service and their health, safety and welfare are protected and promoted by the home`s policies and procedures. Relatives spoken to on the day of the inspection said that `the atmosphere in the home was warm and welcoming and staff always make them feel welcome.` What has improved since the last inspection? As a result of listening to people who use the service the home has introduced new food menus and meals from different cultures have been introduced. Regular meetings with the cook take place and any suggestions made are acted upon. The home has purchased new crockery and tablecloths to add to the ambience of meal times. The home has reviewed the key worker system to ensure key workers are introduced at the assessment stage. This means that people using the service are fully informed of what they can expect from their key worker. The care plans have been reviewed to ensure that they are clear and written in a personalised manner detailing how individuals` identified needs should be met. Medication cabinets have been fitted in all bedrooms to promote safety and independence. As a result of a suggestion from relatives the home has introduced a photo board with staff photographs identifying their names and positions. Staff knowledge and understanding in safeguarding matters is constantly being checked at team meetings. This means that people`s safety is promoted. People using the service are involved in staff recruitment and their opinions are valued and acted upon. Several bedrooms have been redecorated and floor coverings have been replaced which means that people live in a home that is safe and well maintained. What the care home could do better: The manager and staff continue to offer a high standard of care to people living in the home and are aware of the areas that need improving. Consideration must be made to ensure that any gaps in employment records are explored at the interview and the reason for any gaps recorded on the interview record. Key inspection report Care homes for older people Name: Address: The Willow 110 Chartridge Lane Chesham Bucks HP5 2RG     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: Joan Browne     Date: 1 6 1 0 2 0 0 9 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) 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 Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: The Willow 110 Chartridge Lane Chesham Bucks HP5 2RG 01494773451 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: woodstockconkers@aol.com Mrs Lynne Woodstock,Mr Mason David Duke care home 10 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 10 The registered person may provide the following category/ies of service only: Care home only - 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 - OP Date of last inspection Brief description of the care home The Willow is a privately owned care home providing personal care and accommodation for up to ten older older. The home is located on the outskirts of Chesham and is a short distance from local amenities. The home is a domestic type residence, which is situated in a residential area of Chesham and has been sympathetically extended and refurbished to meet the needs of people using the service. Accommodation is situated over two floors. The sitting room has been extended into the conservatory. There is a large domestic type kitchen/diner adjacent to the lounge. Care Homes for Older People Page 4 of 26 Over 65 10 0 Brief description of the care home The dining area in the kitchen appears to be a key area within the home as it is centrally placed and appears to be a common meeting place for people using the service, staff and visitors. All bedrooms provide single room accommodation. With the exception of one room all are fitted with en-suite facilities. There is no passenger lift therefore, individuals who are considering moving into the home must have some mobility. The home has a small driveway at the front with adequate parking for a number of vehicles. At the rear of the building there are beautifully landscaped gardens. Information regarding the services offered is available from the home on request. 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: This unannounced key inspection was carried out on the 16 October 2009 and covered all of the key National Minimum Standards for older people. The inspection lasted for approximately five and a half hours. commencing at 10:05 am and concluding at 15:30 pm. The last key inspection on this service was completed on 11 October 2006. Prior to the inspection a detailed self assessment questionnaire known as the annual quality assurance assessment (AQAA) was sent to the manager for completion and surveys were sent to a selection of people living at the home, staff and visiting professionals. The AQAA was returned by the due date and contained detailed information demonstrating how the home had listened to people using the service and their relatives and recognising the areas that it still needs to improve in and how it was planning to do this. Five staff members, one person using the service and a health care professional completed surveys and their replies have helped to form judgments about the service. The manager, deputy manager, three staff members, three relatives and people using Care Homes for Older People Page 6 of 26 the service were also involved in the inspection process and their responses and views of the home have been incorporated into the report. Further information was gained by observing staffs practice, examination of care plan documentation, staffs records, health and safety records and a tour of the premises. Feedback was given to the manager and deputy manager on the inspection findings. There were no requirements and recommendations made on this visit. We (the Commission) would like to thank all the people using the service, relatives and staff who made the visit so productive and pleasant on the day. Care Homes for Older People Page 7 of 26 What the care home does well: What has improved since the last inspection? What they could do better: The manager and staff continue to offer a high standard of care to people living in the home and are aware of the areas that need improving. Consideration must be made to ensure that any gaps in employment records are explored at the interview and the reason for any gaps recorded on the interview record. Care Homes for Older People Page 8 of 26 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 9 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 10 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The care needs of prospective people to use the service are assessed prior to admission this enables the home to be sure that it is able to meet individuals diverse needs. Evidence: Examination of care plan documentation demonstrated that the home ensures that no person is admitted unless a pre-admission assessment is carried out. This ensures that the home and the staff team can meet individuals identified needs. We were told that assessments are carried out by the manager or deputy manager in individuals homes. Prospective people and their families are invited to visit the home to spend sometime and get a feel of the home. A four week trial period is offered to individuals to enable them to make a decision on the placement. The manager explained that during the trial period the staff team provide re-assurance and support to individuals during this potentially difficult time. As part of the process the home obtains feedback from individuals to improve on the pre-admission process and to ensure that peoples Care Homes for Older People Page 11 of 26 Evidence: diverse needs were being met. We spoke to three relatives during the inspection and they confirmed that the home provided adequate information and answered all their questions. The following comments were noted from relatives:The staff ensure that my mothers needs are fully met. They provide all the things that they say they would do. I cant fault the home they make sure that individuals needs are met. The home does not provide intermediate care. Care Homes for Older People Page 12 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. The home ensures that people using the service receive effective personal and health care support using an individualised approach which is base on the rights of dignity equality fairness autonomy and respect. Staff empower people using the service to be independent. Evidence: We looked at three peoples care plan. These were clear detailing how individuals identified needs relating to all aspects of their health, personal and social care would be met in a personalised manner. Individuals religious, and cultural needs were detailed in the care plans. It was noted that the home assesses peoples capacity to make decisions. Not all assessment sheets seen were signed and dated. As with all care planning documentation sheets should be signed, dated and kept under review. It was noted in one particular care plan that the individual had suffered from seizures in the past. The manager was advised to detail in the care plan the action to be taken by staff should the individual sustain any further seizures. It was evident that people using the service and their representatives were involved in the development of the care plans. For example, all the care plans seen were signed by individuals and their Care Homes for Older People Page 13 of 26 Evidence: representative. Staff involved in the monthly review of care plans signed and dated them. Risk assessments relating to moving and handling, falls, and tissue viability identified potential and actual risks and detailed how risks would be managed. People using the service were registered with a general practitioner (GP) of their choice. Visits were recorded in the care plan documentation. People have access to specialist health care professionals via the GP surgery. The AQAA informed that the home has a good relationship with the local surgery and the district nursing service. The district nurse was spoken to on this visit and she confirmed this and was complimentary on the high standard of care that the home was providing. The following comments were noted from a health care professional:I am very impressed with this home and feel it is the best home in the area. Relatives spoken to were also complimentary about the high standard of care that the homes staff were providing. The following comments were noted: I am always kept informed of my mothers care and if she is unwell. We were told that the chiropodist and hairdresser visit the home as and when required for a small charge. Care staff identified as capable to administer medication are expected to leave a sample of their signature in the medication folder. A recent photograph of individuals were included in their personal folder and medication record folder to reduce the risk of errors occurring during medication administration. We were told by the manager that several persons were assessed as capable to self-medicate and the appropriate risk assessments were in place. Medication cabinets had been fitted in all the bedrooms to promote independence and privacy. The medication administration record sheets were checked and there were no gaps. There were no controlled drugs in the home on the day of the site visit. The home has a protocol in place for the administration of homely remedies which was agreed by the general practitioner. There was a clear audit trail of medicines entering and leaving the home. We observed staff treating individuals in a friendly and respectful manner. Those spoken to rate the personal care they receive as excellent. They unanimously said, we are treated with respect. People were dressed appropriately for the weather and their attire was clean and tidy with attention to detail. Care Homes for Older People Page 14 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that people using the service are involved in meaningful daytime activities which meet their choice, interests and diverse needs. Individuals are able to maintain contact with their family and friends. Meals provided were of a high standard and served in pleasing surroundings. Evidence: The homes daily routine was flexible and fitted around peoples diverse needs and preferences. Staff spoken to confirmed that individuals were encouraged to lead a lifestyle of their own choice, partaking in activities as and when they wish to both in the home and within the community. The AQAA informed that an assessment of peoples social and recreational needs is carried out to determine their interests and preferences. The home employs an activity person twice a week. She confirmed that the views of individuals are sought and their varied interests are considered when planning activities. Individuals wishes were respected and they are not forced to participate in any activity if they do not wish to. Some people prefer to have one to one activity. On the day of the inspection a quiz game was facilitated and one individual made gift tags. The AQAA informed that the home produces a newsletter to inform people using the service and relatives of events planned in and out of the home. There was a selection of reading material available in the home to stimulate Care Homes for Older People Page 15 of 26 Evidence: peoples interests. A local church group visits the home monthly to offer communion. Individuals are invited to church functions and they choose if they wish to attend. Christian festivals are celebrated as well as peoples birthdays. The home does not have any restrictions on visiting. Family and friends are able to visit at anytime and are able to overnight if they wish to. Relatives spoken to during the inspection confirmed that staff make them feel welcome and provide them with refreshments. The following comments were noted: The home is warm and welcoming. I am always provided with refreshments when I visit my mother. The staff encourage the residents to see it as their own home which is wonderful. The staff encourage people using the service to exercise personal autonomy and choice and to handle their own financial affairs for as long as they wish to and have the capacity to do so. Individuals are encouraged to bring personal possessions and furniture to personalise their rooms. The menu seen was varied to ensure that peoples likes and dislikes were catered for. Three meals were provided daily and hot and cold drinks and snacks are available at all times and offered throughout the day. One individual spoken to confirmed that she often helps out at tea time to prepare the evening tea with staff which she enjoys. The AQAA informed that the cook meets with people using the service regularly throughout the year to consult with them about the menu. Minutes of a recent meeting was made available for the inspection process. Individuals spoken to confirmed that they meet regularly with the cook. They also said that if they did not like what was on the menu the cook would provide an alternative. The cook was spoken to and she confirmed that she regularly introduces different types of cultural food for individuals to experience and taste. The verbal and written feedback she had received was positive. One particular person spoken to said that they enjoyed the French and Greek menus. It was noted that staff encourage people using the service to try their own cultural food. For example, Borch a Polish soup made from beetroot was quite a popular choice. Lunch seemed to be a relaxed activity. The menu was displayed on the tables in the dining areas to remind people what was on offer. Staff were patient, helpful and allowed individuals the time they needed to finish their meal comfortably. If required liquidised meals or soft diets can be catered for. People said that the food was excellent, tasty and the right amount. They also said that the cook provided some lovely old fashioned meals. Care Homes for Older People Page 16 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a complaints and safeguarding policy in place which should ensure that people would be confident that their complaints would be investigated and they would be protected from any potential risk of harm or abuse. Evidence: The home has a complaints procedure which is accessible to people using the service, staff and relatives. A copy of the procedure was displayed on the homes notice board. The manager confirmed that the home has not had any complaints for some considerable time. She felt that the reason for this was because the home has an open door policy and encourages relatives and people using the service to express any concerns. People spoken to and relatives said that they have not had the need to make a complaint and were very happy with the care provision. The home has a safeguarding of vulnerable adult policy which incorporates Bucks County Council safeguarding protocol. Training records examined verified that all staff had undertaken updated training in the safeguarding of vulnerable adults. Staff spoken to said that they were clear about what action should be taken if they suspected or witnessed an incident of abuse. The AQAA informed that the homes staff discuss with people using the service individually and in small groups about abuse, the mental capacity act 2005 and deprivation of liberty safeguards (DOLS). It was noted that senior staff had received training in these areas and had cascaded it to the rest of the team. The home has not had any safeguarding referrals or investigations within the last twelve months. 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 excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is well maintained which should ensure that the environment is fully able to meet peoples diverse needs and promote independence. Evidence: The manager and staff encourage people using the service to see the home as their own home. It presents as comfortable and attractive with a homely ambience. All the bedrooms were single occupancy situated on two floor and some have an en suite facility. Aids and adaptation had been fitted in communal bathrooms and toilets to promote independence. Bedrooms seen were personalised with small pieces of furniture, family photographs and mementos reflecting the characters of individuals. The home ensures that regular temperature checks are carried out on the hot water which was within the normal range. The gardens were attractive and well maintained. There is good access to the gardens from various parts of the home. Some individuals spoken to said that they try to go out daily weather permitting to enjoy the gardens. From discussion with the manager it was evident that the home spends money on the environment in the best possible way so that outcomes for people using the service are improved as much as possible. The AQAA informed that the home has a maintenance book which identifies any maintenance issues and these are acted upon. There is also an ongoing maintenance programme to ensure that all areas in the home are maintained appropriately. The following comments were noted from a respondent to the Commissions survey:This is a very happy comfortable and relaxing home for Care Homes for Older People Page 18 of 26 Evidence: the elderly. The atmosphere is first class and all the rooms are spotless. The laundry area was clean and tidy and fitted with the appropriate washing machines with the specified programming ability to meet disinfection standards. On the day of the inspection the home was clean, safe, pleasant, hygienic and tidy and free from offensive odours. Random review of staff training records demonstrated that they had undertaken training in infection control. The area where general and clinical waste is stored was appropriately enclosed to minimise risk of contamination. 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that staff receive relevant training which is aim at delivering improved outcomes for people using the service. The homes recruitment process needs to be more robust to ensure that it complies fully with current legislations. Evidence: The rota demonstrated that the staffing numbers and skill mix of staff were appropriate to meet peoples assessed needs for any twenty-four hour period. Staff who responded to the Commissions survey said that the home was adequately staffed. The home has a programmme of planned training in place and is part of a training cluster group in the local area. The training matrix reflected that mandatory training for all staff was up to date which means that staff were being supported to maintain their competency and fulfill their duties. Staff who responded to the Commissions survey said that they were provided with training which was relevant to their role Those spoken to on the day of the visit confirmed that they attend regular training updates. Seven staff had acquired the national vocational qualification (NVQ) at level 2. There is a stable staff team and staff confirmed that they enjoyed working at the home and felt valued. Team spirit and morale were high. The home ensures that staff undertake induction training to support them in understanding their roles and meeting the needs of individuals in a personalised manner. The manager informed that people using the service are involved in the recruitment of staff. The recruitment files of two recently recruited staff members were examined. It Care Homes for Older People Page 20 of 26 Evidence: was found that they contained two written references, PoVA first checks and criminal record bureau clearances. In one particular file there was no evidence that gaps in the employees records were explored at the interview. The manager said that she was aware of the reasons for the gaps but had not made a note of them on the application form. Recent photographs of staff members to confirm proof of identity were not in the files. The manager is advised to ensure that all employment gaps are explored at the interview and the reasons for gaps recorded on the application form. A recent photograph should be on staff members files to confirm proof of their identity. It was noted that the staffs files contained loose sheets of paper and were not secure. Consideration must be made for sheets to be fixed securely in files so that they can be easily accessible. 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. The manager has the experience to run the home and works to continuously improve the service and provide an increased quality of life for people using the service. Evidence: The registered manager is a registered nurse and has completed the registered managers award. She has several years experience of owning and managing this care service. She is supported by a deputy manager, carers and support staff. The manager confirmed that she updates her knowledge, skills and competence by undertaking mandatory training and had recently undertaken training in the mental capacity act 2005 and deprivation of liberty safeguards (DOLS). In discussion with people using the service, staff and relatives it was felt that the home was being effectively managed and run in their best interests. The manager was able to demonstrate best practice in customer satisfaction and equality and diversity. Regular meetings with staff and people using the service were being held. Staff spoken to on the day of the inspection and those who responded to the Commissions surveys said that they felt valued by the manager and were complimentary about her managerial Care Homes for Older People Page 22 of 26 Evidence: and interpersonal skills. The home has a quality assurance system in place which means that people using the service, staff and stakeholders views are sought to ensure that the home is meeting its aims and objectives and individuals were satisfied with the service delivery. Other quality monitoring such as, auditing of medication administration record (MAR) sheets, care plans and regulation 26 monthly visits were being carried out to assess the standard of the practice and the provision of care in the home. The AQAA contained excellent information that was fully supported by appropriate evidence. The manager demonstrated a high level of self-awareness and recognises the areas that the home still needs to improve in and how it intends to do this. The home does not take responsibility for looking after peoples finances. Family members are expected to assist with this matter. The kitchen was clean and tidy and satisfactorily maintained. We were told that the home was awarded a gold standard certificate for maintaining high standards of hygiene in the kitchen. The AQAA informed that the maintenance of equipment was up to date. A sample of records relating to health and safety was examined and found to be satisfactorily maintained. 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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!