Care Home: Upminster Nursing Home

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What the care home does well Equality and Diversity issues are given a high priority within the home and staff recruitment procedures are robust. Staff training and supervisions is very good and the management team is effective, open and transparent. The dietary needs of the residents are monitored to ensure good nutrition and hydration. Residents are given choices of what and when to eat and are given the appropriate support when required. Medication administration and record keeping is of a good standard with the safety of the residents being paramount. The service has good relationships with the GP, Tissue Viability Nurses and other health and social care professionals. The GP carried out a `surgery` at the home every Monday, which ensures that residents have regular access to a GP. On the day of the inspection asocial and health care professional were visiting a resident. both were very positive about the care being delivered and the health care professional stated, "the resident has improved beyond my expectations, I am astounded". What has improved since the last inspection? There has been a vast improvement in the development of the care plans, they are comprehensive and person centred and there was evidence that they are being regularly evaluated and updated to reflect residents` changing needs. A new activities co-ordinator is in post and her hours have been increased which has had a positive effect on the residents; activities are now suited to individual needs and wishes and this includes spending 1:1 time with residents. All of the staff including the administrator and domestic staff have attended safeguarding adults training and other staff have attended refresher courses. The manager has ensured that staff have the opportunity to attend both mandatory and specialist training; all mandatory training is part of the induction programme and other training includes `end of life`, palliative care, dementia awareness and NVQ 2/3. The storage of surplus stock, such as nutritional supplements have been removed from residents` bedrooms and are now stored appropriately. What the care home could do better: No requirements or recommendations were identified at this inspection, however the manager has identified in her AQAA areas within the service that she will be working on during the next twelve months.; continue with refurbishment programme, ensure that staff have access to specialist training as identified in their training matrix, to encourage relatives to attend resident/relatives meetings and to involve advocates in residents` reviews if appropriate. Inspecting for better lives Key inspection report Care homes for older people Name: Address: Upminster Nursing Home Clay Tye Road Upminster Essex RM14 3PL     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Julie Legg     Date: 1 2 0 5 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. 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. 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 Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 30 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). 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 CSCI 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 30 Information about the care home Name of care home: Address: Upminster Nursing Home Clay Tye Road Upminster Essex RM14 3PL 01708220201 01708641420 jan@haveringcare.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : Havering Care Homes Limited care home 35 Number of places (if applicable): Under 65 Over 65 0 28 dementia old age, not falling within any other category Additional conditions: 7 0 The Registered Person may provide the following categories of service only: Care home with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP (Maximum number of places: 28) Dementia - Code DE (Maximum number of places: 7) The maximum number of service users who can be accommodated is: 35 Date of last inspection Brief description of the care home Upminster Nursing Home is a purpose built care home owned by Havering Care Homes Limited. The home is situated in a rural area between Upminster and North Ockendon. The home can accommodate up to 35 older people and is registered to provide nursing care. The accommodation is on three floors, the lower ground floor, the ground floor and the first floor. There are 35 single bedrooms, all rooms have an en-suite with a toilet and wash hand basin. The home has wheelchair access and a passenger lift is provided. Care Homes for Older People Page 4 of 30 Brief description of the care home On the day of the inspection the range of fees for the home was between 509.00 pounds and 817.00 pounds per week. A copy of the Statement of Purpose and Service User Guide to the home and a copy of the most recent inspection report are located in the reception area or made available on request. Care Homes for Older People Page 5 of 30 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 was an unannounced inspection that was undertaken by the lead inspector Julie legg. It took place on 12th May 2009 between the hours of 10:00 and 17:30. The registered manager was available throughout the inspection and was available for feedback at the end of the visit. The inspection process included information contained in the Annual Quality Assurance Assessment (AQAA), regulation 37 notifications and other records held at the home. A tour of the home was undertaken during which all parts of the home where visited including some of the residents bedrooms. We were able to talk to some of the residents, visiting relatives and two health and social care professionals as well as staff Care Homes for Older People Page 6 of 30 (including the cook and domestic staff). We case tracked four of the residents. We have previously been advised by the manager that the majority of the people living in the home prefer to be called residents. This is reflected accordingly throughout this report. We would like to thank the residents and staff for their input during this inspection. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. Care Homes for Older People Page 8 of 30 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 30 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 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and their relatives have appropriate and detailed information on the home, this will enable them to make a decision as to whether the home is right for them. Evidence: We saw a copy of the Statement of Purpose, Service User Guide and a copy of the last inspection report in the reception of the home. the Statement of Purpose has recently been updated to include information about the new Dementia Unit. Prospective residents and relatives are actively encouraged to visit the home at a time that is convenient to them. On arrival an allocated member of staff will help to make them feel comfortable and to introduce them to residents and staff. One relative stated I visited a number of homes but felt more comfortable here as the manager and staff gave me as much time as I needed and answered all of my questions. I have never regretted choosing Upminster for my Mum. Care Homes for Older People Page 11 of 30 Evidence: The manager or deputy manager carry out a thorough pre-admission assessment that covers all areas of health, social and personal care. Residents files showed that either or both the resident and relatives were involved in the pre-admission assessment. Admission to the home will only take place once the service is confident that the staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. Residents files also showed a copy of a contract or terms and conditions of residency at Upminster Nursing Home. Care Homes for Older People Page 12 of 30 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. Residents receive support with their health and personal care that is person centred. This support is given based on residents rights, dignity, privacy and choice. Evidence: Three residents were case tracked. Discussions took place with some residents, relatives, staff and two health and social care professionals and we observed interaction between staff and residents. There was a noted improvement in the standard, detail and construction of the care plans since the last inspection. Evidence showed that residents receive personal and health care support using a person centred approach. Staff give choice to residents in ways that enable them to make decisions about their daily living such as, choice of food, what clothes they wish to wear, when they want to get up and go to bed as well as what activities they wish to participate in. The home provides care to people living with dementia and the care to these residents is delivered effectively through an experienced and trained staff group.Staff also ensure that any support that is given to Care Homes for Older People Page 13 of 30 Evidence: residents is based on their rights, choice, dignity and Independence. Care plans are evaluated at monthly intervals or sooner if the need arises and written daily logs are a reflection of the care that residents are receiving. Equality and diversity issues are identified and addresses by staff and there was evidence of this in individual care plans. For example, specific religious needs and preferences are clearly recorded and residents are enabled to participate in different religious activities as desired. Specific dietary needs are clearly recorded and residents and relatives confirmed that they are able to have food of their choice and presented in a way that met their needs. It was evident from the care plans seen and through discussion with the residents and relatives and staff that residents health care needs were understood and being met on a daily basis. All of the residents have access to health professionals both in the home and from the community. Weights are being monitored on a regular basis, the frequency increased were there is cause for concern and referrals are made to the GP and/or the dietician when required. Equipment and aids are used where necessary and the home is currently upgrading all of the beds to electric profilers and high risk pressure relieving mattresses and the manager is currently looking at assisted technology to reduce the number of falls for those residents who have been identified as at a risk of falling. Records were looked at and discussions took place with the manager and nursing staff regarding the administration, recording storing and disposing of medication and these were all found to be in accordance with the homes policies and procedures. Controlled drugs were also being stored, administered, recorded and disposed of appropriately. From observations and discussions with staff, residents and relatives it was evident that the privacy and dignity of residents is being respected. Staff were observed talking and reassuring residents when carrying out moving and handling tasks and knocking on residents bedroom doors before entering.We spoke to several residents and relatives and asked about the care in the home, everyone was very complimentary in the way that care was delivered: They are wonderful, nothing is too much trouble, they treat Mum as if she was one of their own. A health professional who was visiting the home at the time of the inspection stated I am absolutely amazed at the improvement in her health and her emotional well being. The home is able to meet the needs of residents requiring end of life care. Residents wishes or where appropriate those of the relatives are recorded and include advance Care Homes for Older People Page 14 of 30 Evidence: directives. Staff have attended end of life care training at the local hospice and the home works closely with other health professionals such as the Palliative Care Team. Care Homes for Older People Page 15 of 30 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are supported to remain as independent as possible, to excercise choice and express their wishes and needs. Evidence: The home employs a full-time activity co-ordinator who works closely with the staff in delivering a person centred range of activities. From talking to residents, relatives and staff as well as looking at records, it was evident that residents are involved in the daily life and social activities of the home. There is a general programme of planned activities such as, quizzes, bingo, dominoes, manicures, films and reminiscence sessions. There is also a regular church service, the mobile library service visits every six weeks as well as Age Concern dementia library and the home has regular entertainers visit the home. There are also themed celebrations such as , Christmas, Easter, Halloween, St Georges day, Shrove Tuesday and a Garden party. All of the residents celebrate their birthday with a home baked cake and balloons (if they wish). There is a hairdresser who visits every week. The home is due to take delivery of a new mini bus within the next couple of weeks, this will enable residents to have easier access to the community. Care Homes for Older People Page 16 of 30 Evidence: During the morning of the inspection the activity co-ordinator was sitting with some of the residents talking about articles in the daily newspaper and another small group were taking part in a quiz. In the afternoon a church group visited the home where residents could choose to sit and sing hymns and another group of residents were in the small lounge watching a DVD of the 1966 World Cup. The activity co-ordinator was also seen talking to residents individually. Some of the residents from the dementia unit came along and joined in with the hymn singing. All of the residents have the choice to have their own private telephone line in their bedrooms and a broadband connection has been installed to enable residents or visitors to use the internet or communicate electronically through emails. The manager meets with the residents and relatives every two months to look at the progress of the home and discuss forthcoming events, this also gives the residents and an opportunity to provide suggestions regarding any aspects of the home. Relatives and friends are encouraged to visit whenever they wish, the visitors book showed that there is a steady stream of visitors to the home. One relative said, I visit at all different times but I am always made to feel welcome. Some of the residents are taken out by their relatives. Life history books are being developed and these will be a useful tool for staff particularly during reminiscence activities and the manager is looking to install wall murals which will give the residents interesting things to look at, touch and feel. Meals are mainly served in the dining room on the ground floor, though residents have the choice to eat in the small lounge or their bedroom.The home has produced pictorial menus which helps some residents to make their own choices and staff were observed in explaining to residents what the choices were. We observed lunch being served and the meals appeared well balanced and catered for the different dietary needs of the residents. Some of the residents required support with eating their meal and this was carried out by staff in a sensitive manner. We spoke to the cook who was very knowledgeable of the residents dietary requirements and their likes and dislikes. She advised that all of the food was homemade including cakes, pies and pastries. on the day of the inspection some of the residents had chosen fish and chips and the cook advised that she had made the batter (for the fish) herself. Throughout the visit we observed staff allowing residents to express their wishes and to support them to make choices in their everyday lives such as, what they wanted to Care Homes for Older People Page 17 of 30 Evidence: eat, where they wanted to sit and whether they wanted to join in an activity. Staff spoke of Upminster Nursing Home being the residents home and that they were committed to making this as pleasant as possible. Care Homes for Older People Page 18 of 30 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. Residents can feel confident that their complaints and concerns are listened to and acted upon and that they are protected from abuse. Evidence: The home has a written policy and procedure for dealing with complaints. Copies of the complaints procedure and details of an advocacy service are readily available. Staff that were spoken to were aware of the complaints procedure and how to deal with concerns or complaints that were made to them. residents and relatives told us that they were very satisfied with the service and that they felt safe and supported. One resident said I dont have any complaints but if I did I would see the manager, a relative stated I did have a concern but I told Jan (manager) and it was put right before I had left the building. The AQAA identified that during the past twelve months there have been no complaints but one safeguarding referral that resulted in a referral to the Protection of Vulnerable Adults List (POVA). All staff have undertaken training in safeguarding vulnerable adults and this is included in induction training for all newly recruited staff as well as further training. There is also a policy on whistle blowing and challenging bad practice at work. Staff that were spoken had a good understanding and knew what to do if they had concerns about the safety and welfare of residents. They told us that they had attended training and that they were aware of the homes policy and procedures Care Homes for Older People Page 19 of 30 Evidence: regarding safeguarding adults. All staff including ancillary staff have undertaken appropriate training and this was confirmed by looking at staff files. The home has policies and procedures for the safeguarding of residents monies and there was evidence that all financial transactions are robust. There was evidence that any equipment that may be used to restrain residents such as, bed rails, recliner chairs and wheelchair belts have been risk assessed and are only used when necessary and there is no safe alternative. Care Homes for Older People Page 20 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The atmosphere in the home is very welcoming and provides a physical environment that is appropriate to the needs and lifestyle of the residents who live there. Evidence: We undertook a tour of the home taken accompanied by the manager and found all areas to be clean and free from offensive odours.The home is decorated and furnished to a good standard and there is a continuous programme of redecoration and refurbishment which ensures that the standard of the home is maintained. All of the bedrooms are single and en suite and have been individually decorated and furnished. Residents are encouraged to furnish their bedroom with some of their own possessions to reflect their interests, culture and religion. The manager is in the process of placing relevant photographs on residents bedroom doors, this will assist the residents in recognising their own bedroom. The home has specialist aids and equipment to meet the needs of the residents and there is a call alarm system fitted to each bedroom which is within easy reach of each residents bed. There are sufficient toilets and bathrooms to meet the needs of the residents and there is plans for the bathroom on the lower ground floor to be converted to a wheelchair accessible shower room. Care Homes for Older People Page 21 of 30 Evidence: The communal areas of the home consist of a large lounge/dining room from which the garden can be accessed and a quiet lounge, these are situated on the ground floor and there is also a quiet lounge on the dementia unit. Large flat screen televisions have been purchased which will assist those residents with poor sight. Staff are aware of the need to excercise good infection control. We were told there are more than adequate supplies of disposable gloves, aprons and alcohol gel, colour coded laundry bags for seperating laundry items and new products have been purchased for cleaning and eliminating odours. there is always sufficient hot water and the temperature in the home can be changed to meet the choice of the residents, especially in their own bedrooms. We visited the kitchen and laundry and these were found to be clean and well maintained. The garden is area is well maintained and the external walkways and fire exits have been painted with a non slip paint. Care Homes for Older People Page 22 of 30 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. There are sufficient staff on duty who are trained and skilled to meet the needs of the residents. Evidence: The staffing levels and skill mix of the staff team are in line with meeting the diverse and changing needs of the residents. Staff were being effectively deployed so as to ensure that residents choosing or needing to remain in their bedrooms were cared for appropriately. All of the staff were seen to interact and communicate well with all of the residents. Staff that were spoken to were clear about their roles and their responsibilities and demonstrated a strong commitment to provide good quality care to the residents. There is now a fairly stable staff team which means that residents receive consistent care from staff that know them well. The service was able to demonstrate that they operate a robust recruitment and selection process in accordance with the requirements of legislation, equal opportunities and anti discriminatory practice. Staff can only commence employment once all of the appropriate checks have been received and are satisfactory. All nursing staff working at the home are suitably registered with the appropriate body. Staff training is seen as a high priority and the manager ensures that the training will Care Homes for Older People Page 23 of 30 Evidence: enhance the knowledge and skills of the staff. Some of the training is provided by external facilitators and other training courses are in-house. All staff undertake an induction programme and for care staff this is in line with Skill for Care. Staff have received all mandatory training as well as specialist training such as, dementia awareness, palliative care, medication and safer food better business. the manager has received training in the Mental Capacity Act and is organising staff to receive training in this important area. the majority of the staff have NVQ 2 and five of the care staff are working towards their NVQ 3. Regular staff meetings are taking place and are used for consultation and training, there is also evidence that staff are receiving regular supervisions and yearly appraisals. The manager has produced a training matrix for all of the staff and this is assisting her in planning future training courses. Residents and relatives were complimentary of the care received at Upminster Nursing Home. One resident said I have no complaints whatsoever, nothing is too much trouble, another stated they look after me very well. A relative stated I am very happy with the care my Dad receives. Care Homes for Older People Page 24 of 30 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 management of the home ensure that the home is run in the best interests of the residents, this is achieved by effective quality assurance systems and promotion of high quality care. Evidence: The registered manager has the necessary qualifications and experience to manage the home. She holds a nursing qualification, the Registered Managers Award (RMA) with seven years managerial experience, a diploma in safety management and is an NVQ assessor. She is currently undertaking a one year diploma course in dementia care. She understands and values the opportunities for continuing her professional development. She has sound financial planning and budgetary control and the home provides value for money. In discussion with the manager she was able to describe a clear vision of the home and it was evident that she communicated a clear sense of direction for her staff. Care Homes for Older People Page 25 of 30 Evidence: Equality and diversity, human rights and person centred thinking are given a priority by her and she was able to demonstrate a high level of understanding and best practice in these areas. The management team operates robust operational systems and are knowledgeable and highly competent in a range of areas. The senior nurse has responsibility for health & safety issues and is a train the trainer in moving & handling. Other maintenance records that were seen were in good order and the management team and the maintenance person work closely together to ensure that the home is maintained to a high standard. Staff spoke highly of the manager and told us that she and the deputy provide good role models, that they are supportive and are very much team players. Training and development of staff is given a high priority within the service. The manager ensures that staff follow the policies and procedures of the home and spot checks are part of the quality monitoring systems to ensure that good practice is followed. The manager has an open door policy and the views of the residents and staff are listened to and acted upon. there are effective quality assurance systems and these include monthly visits as required under Regulation 26 of the Care Homes Regulations. these reports are kept at the home and were seen during the inspection. The Annual Quality Assurance Assessment (AQAA) was comprehensive and was supported by evidence during this inspection. She has a clear understanding of what further improvements are needed and what areas need to be developed. There are sufficient systems to ensure the effective safeguarding and management of residents money and valuable, including record keeping. records are kept securely and staff are aware of the Data Protection Act. There are clear written records of all safety checks and accidents and the manager complies with reporting incidents/events under Regulation 37 of the Care Home Regulations. The management team and all of the staff demonstrated a good understanding of risk assessment processes which were underpinned by promoting Independence, choice and autonomy. Currently no resident has been registered under the new deprivation of liberty safeguards and no applications have been made nor refused by the local authority. the manager was conversant with the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DOLS). Training has been arranged for staff so that they are conversant with the DOLS. Care Homes for Older People Page 26 of 30 Care Homes for Older People Page 27 of 30 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 28 of 30 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 29 of 30 Helpline: Telephone: 03000 616161 or Textphone: or 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) Commission for Social Care Inspection (CSCI). 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 CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 30 of 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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