Care Home: Waters Edge Care Home

Similar services:

• Maple Lodge
• Heathlands
• Aston Court Nursing Home
• Breme
• Ravenhurst
• Bank House
• Inspirations
• Ashcroft Hollow Nursing Home

What the care home does well The Statement of Purpose and Service User Guide had recently been reviewed and were available for us to view. The previous inspection report is available to read in the main entrance hallway of the home. We examined four care plans. These were signed for by the individual, and followed a clear and comprehensive format, with clear instructions to staff on how to care for each individual. People we spoke to told us they had been involved in their care planning processes and their review. Activities are organised on a programmed basis, and programmes were on display via notice boards throughout the home. People spoken with, and surveys received confirmed that they had been given a copy of the complaints procedure, and knew who to complain to. They said that their grumbles are listened to and acted upon by staff. One relative spoken with said, "I have not had cause to complain, but I can alway pop in and see the manager any time." The home provides a clean, well maintained environment throughout. Individual bedrooms were personalised, and contained homely, comfortable furnishings. Staffing levels had been maintained, and there is a good system in place for the safe recruitment of staff. What has improved since the last inspection? The Annual Quality Assurance Assessment document, completed by the care manager told us about the following improvements: "Monthly managers training day at head office. Operations feedback form which is completed and emailed to head office. Policy and procedures have been improved We have reviewed our practices in line with new legislation e.g. Dols/ mental capacity act. We have a 5 day induction programme and the home is committed to having a care team that has a full understanding of the needs of the residents. We listen attentively to the staff and residents and act upon any issues/concerns they have. Continue to provide as much training as possible and take advantage of long distance training. Staff have enrolled on the palliative care course, this will improve staff confidence. We hold more meetings involving the residents and families. We have changed entertainers that come into the home and where we take the residents on trips. We have weekend activities and have involved the community in our activities. The British Legion, Alzheimers Society and Dementia care support. The organisation introduced complaint cards and comment cards. This makes the complaints procedure easier for the residents. They are in the residents rooms and displayed in the reception. We maintain open and honest communication with residents and their families.Rooms that have been refurbished are of a high standard. The organisation is committed to improving the environment and any Health and Safety issues in and around the home. We have provided defibrillator training and there is a defibrillator on site. The manager and deputy have been trained as trainers with the defibrillator so they can refresh staff in the use of the defibrillator and train new staff." What the care home could do better: When a person is being discharged from hospital, the care manager should ensure that the individuals care plan is kept under review, so that staff have clear and up to date instructions, and know how to care for that person. People using the service should be able to have their say about what is on their menu. Shelving should be installed in en-suite bathrooms to enable the safe storage of toiletries. Quality assurance systems should be expanded to include other health professionals. Results from surveys should be collated and feedback to people using the service and staff. Key inspection report Care homes for older people Name: Address: Waters Edge Care Home Stafford Road Great Wyrley Nr Walsall West Midlands WS6 6BA     The quality rating for this care home is:   two star good 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: Pam Grace     Date: 2 8 0 7 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 27 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 27 Information about the care home Name of care home: Address: Waters Edge Care Home Stafford Road Great Wyrley Nr Walsall West Midlands WS6 6BA 01922409898 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: manager@alphalakes.demon.co.uk Alpha Care Homes care home 63 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia mental disorder, excluding learning disability or dementia old age, not falling within any other category physical disability Additional conditions: The maximum number of service users who can be accommodated is: 63 The registered person may provide the following category 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 (OP) 63 Dementia (DE) 10 Mental Disorder, excluding learning disability or dementia - over 65 years of age - (MD(E)) 6 Physical Disability (PD) 16 Date of last inspection 10 0 0 16 Over 65 0 6 63 0 Care Homes for Older People Page 4 of 27 Brief description of the care home Waters Edge is a sixty-three bedded care home situated in Great Wyrley on the main A34 Cannock to Walsall Road. Public transport passes by the home. Accommodation is situated on the ground and first floor, the first floor being accessed by a passenger shaft lift. There are four shared bedrooms and fifty-five single bedrooms all of which have en/suite facilities. There are three lounges and a dining room on each floor, six bathrooms all of which have assisted bathing facilities, plus two shower rooms. Separate toilets for communal use are appropriately sited around the home. The home has been purpose built. Specialist services including the continence advisor, chiropodist, optician, audiologist, diabetes nurse and district nursing service are made available to the people using the service. Care Homes for Older People Page 5 of 27 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: two star good 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 key unannounced inspection was carried out over one day, by one inspector. The inspection had been planned using information gathered from the Care Quality Commission (CQC) database, the Annual Quality Assurance Assessment (AQAA) document that had been completed by the registered care manager, and comments/surveys received from people who use the service and their relatives. The key National Minimum Standards for Older People were identified for this inspection and the methods in which the information was gained for this report included case tracking, general observations, document reading, speaking with staff, people who use the service and their visiting relatives. Observation of the environment was also undertaken. People spoken with were very positive about the care they were receiving. We observed people who were unable to communicate. Our observations showed that Care Homes for Older People Page 6 of 27 these people were well cared for, and were happy in their surroundings. There had been no complaints made to the home, and one safeguarding adult protection referral had been made since the previous inspection. Surveys returned to the Care Quality Commission totalled 8 Have Your Say documents. The feedback and comments we received from people about the service were generally positive. At the end of our inspection, feedback was given to the care manager, outlining the overall findings of the inspection, and giving information about the requirements and recommendations that we would make. There were no requirements, and four recommendations made as a result of this unannounced inspection. Care Homes for Older People Page 7 of 27 What the care home does well: What has improved since the last inspection? The Annual Quality Assurance Assessment document, completed by the care manager told us about the following improvements: Monthly managers training day at head office. Operations feedback form which is completed and emailed to head office. Policy and procedures have been improved We have reviewed our practices in line with new legislation e.g. Dols/ mental capacity act. We have a 5 day induction programme and the home is committed to having a care team that has a full understanding of the needs of the residents. We listen attentively to the staff and residents and act upon any issues/concerns they have. Continue to provide as much training as possible and take advantage of long distance training. Staff have enrolled on the palliative care course, this will improve staff confidence. We hold more meetings involving the residents and families. We have changed entertainers that come into the home and where we take the residents on trips. We have weekend activities and have involved the community in our activities. The British Legion, Alzheimers Society and Dementia care support. The organisation introduced complaint cards and comment cards. This makes the complaints procedure easier for the residents. They are in the residents rooms and displayed in the reception. We maintain open and honest communication with residents and their families. Care Homes for Older People Page 8 of 27 Rooms that have been refurbished are of a high standard. The organisation is committed to improving the environment and any Health and Safety issues in and around the home. We have provided defibrillator training and there is a defibrillator on site. The manager and deputy have been trained as trainers with the defibrillator so they can refresh staff in the use of the defibrillator and train new staff. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 27 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 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. Evidence: The Annual Quality Assurance Assessment document (AQAA), which was completed by the care manager, told us: We actively encourage a pre-admission visit for the relatives and resident when it is possible. We offer a friendly and welcoming environment in which we provide a caring professional service. At Waters edge we have provided excellent end of life care for those residents that want to remain in their own home. Some staff are in the process of completing a palliative care course and end of life through Warwick College. We value individuality and ensure the fulfilment and recognition of the individuals. Ensuring their needs are met through regular reviews with social workers, care team and activity co-ordinators. There are six monthly audits and monthly audits in the home. Care Homes for Older People Page 11 of 27 Evidence: We were given copies of the Statement of Purpose and Service User Guide to look at. We saw that these documents had been reviewed since the previous inspection. However, the documents were undated, and the contact details for the Care Quality Commission needed to be updated and amended. The previous inspection report was readily available in the main office for people to look at. We recommended that this is displayed in the main entrance hallway. People spoken with, and feedback from surveys undertaken confirmed that they had received appropriate information prior to admission, which had included the Statement of Purpose. That they had been able to visit the home, and spend time talking with people who use the service to help them decide if the service would be suitable for them. People also confirmed that they had been provided with a contract/terms and conditions. The provider confirmed that contracts had all been reviewed. We looked at four care plans. These showed that an assessment of needs had been undertaken for those individuals on admission. More recently, the service has introduced a new format for pre-admission assessments, this was discussed with the care manager at the time of our visit. Intermediate care is not provided in this home. Care Homes for Older People Page 12 of 27 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive is based on their individual needs. People should have their needs re assessed as and when it is appropriate to do so. Evidence: The Annual Quality Assurance Assessment document (AQAA), which was completed by the care manager, told us: We continue to deliver a personalised plan of personal care for each individual. There is a stable workforce and this provides continuity to the care provided. We listen to our service users and their families and gain feed back through meetings, questionnaires, audits and surveys. We ensure we provide a safe homely and private environment that promotes good health and privacy during personal care. We examined four care plans. These were signed for by the individual, and followed a clear and comprehensive format, with clear instructions to staff on how to care for each individual. We spoke with staff, people who use the service, and their visiting relatives. Staff spoken with could tell us exactly how each of these people were to be cared for, what these staff told us reflected what was written in individuals care plans. Care Homes for Older People Page 13 of 27 Evidence: People we spoke to told us they had been involved in their care planning processes and their review. One person had just returned to the home from hospital, and needed to be reassessed, so that staff knew how to care for them. We highlighted the need to urgently complete the re-assessment, to enable this. This was discussed with the care manager at the time of our visit. Care plans seen evidenced that pre-admission assessments had informed the care plan. There was also evidence of health professionals involvement, for example District Nurse, General Practitioner, Chiropodist. Brief details were recorded in the event of terminal illness. Risk assessments and activities of daily living were well documented, and contained a lot of detail, with a social history of the individual. These had been reviewed on a monthly basis. The care manager confirmed that the tissue viability specialist nurse would be consulted where necessary in relation to a person requiring more complex treatment. District nurse records were evident in relation to wound care and treatment given to people using that service. Those records were kept separately in individual bedrooms. People spoken with during our visit said that they were very satisfied with the care they receive, and that they were only to ask for help, and staff gave them help. One person confirmed her satisfaction with the care she was receiving, she said, the staff worked hard, and I can trust the staff. Care Homes for Older People Page 14 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are enabled to make choices about their life style and supported to develop their life skills. Social, educational, cultural and recreational activities meet individuals expectations. Evidence: The Annual Quality Assurance Assessment (AQAA) document, which was completed by the care manager, told us: We have a dedicated activities team and there are daily activities morning and afternoon in the home. Each resident have their own activity care plan and a care plan that is centred around the individual. Activity staff provide individual and group activities to meet the needs of the individual. There are outings to shows, theatres and shopping trips. We arrange for shows to come into the home and encourage families to attend. We have a monthly news letter full of information about the activities, also on display in reception is a list of the weeks activity. Care Homes for Older People Page 15 of 27 Evidence: Activity staff have been trained in creating activities for the residents and their individual needs. We spoke with staff, the care manager, and people using the service, they confirmed that there are two activities co-ordinators employed at the home one is full time, and one is part time. There had been a party the day before our visit to celebrate the 8th birthday of the homes opening. This had reportedly proved very popular. Activities are organised on a programmed basis, and programmes were on display via notice boards throughout the home. People spoken with said theres a good range of activities here,we receive care, activities, trips, and this is a clean home with friendly staff. Records seen told us that activities are very popular at the home. People told us about their experience of activities which included a Pat the Dog service, armchair excercise, bingo, reminiscence group, quizzes, music, darts, mystery tours and trips out, and seasonal activities such as going to the christmas pantomime, and making christmas and easter cards. There is a visiting minister for people who wish to attend his service. One of the lounges has been set up as a quiet, restful area, with background music and comfortable furnishings. This can be used by visitors and people using the service. We saw photographs of people taken during outings and activities, these were on display in the main corridors of the home. Meals are cooked by the sister home, and are then sent over via a heated trolley. People spoken with confirmed that meals are hot, and that they are happy with the variety of meals provided, one person said theres plenty of food, sometimes too much. However, people also said that they were unable to have their say about menus, as although there are meetings for people using the service, the chef sets the menu without consulting people first. This was highlighted and discussed with the care manager at the time. Care Homes for Older People Page 16 of 27 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. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure. People are protected from abuse, and have their rights protected. Evidence: The Annual Quality Assurance Assessment (AQAA) document completed by the care manager, told us: We provide a clear and accessible complaints procedure. Information is provided in reception and in the residents rooms. We also provide clear information to the residents families and how to raise a complaint. Written complaints are addressed within 20 days. Staff are trained in how to recognise abuse and the mental capacity act. They are able to demonstrate a good understanding of abuse. We document in the residents care plan their preference of either male or female to attend to their care needs. There is a complaints log and response following a complaint. Staff are encouraged to be proactive in dealing with complaints. We saw that the complaints procedure was displayed in the main entrance to the home, and is also contained within the Statement of Purpose and Service User Guide. People spoken with, and surveys received confirmed that they had been given a copy of the complaints procedure, and knew who to complain to. They said that their grumbles are listened to and acted upon by staff. One relative spoken with said, I have not had cause to complain, but I can alway pop in and see the manager any Care Homes for Older People Page 17 of 27 Evidence: time. The care manager confirmed that the organisation recently introduced complaint and comment cards, which are made available to all visitors, and people using the service. She also told us that she often has a chat to relatives and visitors, and that the home has an open door policy in regard to complaints. Complaint records were available for us to view. There had been no complaints since the last inspection, and one Safeguarding Protection of Vulnerable Adult (POVA) referral had been made to Social Services in that time. We spoke with staff, and looked at the training matrix. Staff said that they had attended update and refresher training in regard to the Protection of Vulnerable Adults. We looked at staff recruitment records, and spoke with staff. We saw that appropriate security checks had been undertaken by the provider prior to their employment. These included Protection of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) checks. A spot check of peoples finances showed that amounts held, tallied with the amounts shown on the records. Receipts are kept for all purchases made on behalf of individuals using the service. Care Homes for Older People Page 18 of 27 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 physical design and layout of the home enables people who use the service to live in a well-maintained and comfortable environment, which encourages independence. Evidence: The Annual Quality Assurance Assessment (AQAA) document, completed by the care manager, confirmed that all health and safety checks on equipment and fire systems had been undertaken, and told us: We continue to maintain a safe and homely environment that meets the residents needs. All our rooms have en suites and there is only 1 shared room which is occupied with a married couple. We have regular Health and Safety meetings that are minuted and feed back is given to facilities at head office. There is a Hot Button form that goes to head office every week and any work required or outstanding can be raised in their weekly meeting. As the rooms become vacant they are being redecorated and will be re furnished. There is a full time maintenance Handy man that can undertake minor problems. There are 2 part time gardeners to keep the grounds maintained. Rooms that have been refurbished are of a high standard. The organisation is committed to improving the environment and any Health and Safety issues in and around the home. Relatives and people spoken with during the inspection visit expressed their satisfaction with the general environment, their room, and the equipment provided within the home. They said, its kept clean and tidy, and the staff try very hard to Care Homes for Older People Page 19 of 27 Evidence: keep it all clean, it is truly a comfortable home, quite different from any other old persons home. We observed the environment. The home provides a clean, well maintained environment throughout. Individual bedrooms were personalised, and contained homely, comfortable furnishings. However, people would benefit from shelving in en-suite bathrooms, to ensure the safe storage of toiletries. This was highlighted and discussed with the care manager during our visit. We noted that equipment and adaptations were provided as necessary to maximise independence. For example, wheelchairs, raised toilet seat, bed rails, pressure mattress, handrails, and assisted baths. The upstairs servery which is used by staff to make drinks for people using the service, was out of action, as plumbing work needed to be undertaken. However, the downstairs servery was available. The laundry areas were clean and tidy, with appropriate measures in place to prevent cross infection. Care Homes for Older People Page 20 of 27 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. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. Evidence: The Annual Quality Assurance Assessment (AQAA) document, completed by the care manager, told us: We have a loyal and long service care team. 80 per cent of the care team have NVQ 2, 25 per cent have NVQ3, and there are 2 staff enrolling on NVQ4 in June 2009.They are able to demonstrate a good understanding and commitment to meeting the individuals needs. Staff turnover is low. There is a robust policy and procedure for interviewing and recruiting staff. There are long service awards within the company. We have a career of the year award and they are nominated by their colleagues. A competent person has been trained to give supernumerary support to the new staff. All new staff have reviews monthly for the first 3 months and they have a 6 month probation period with the company. Staff rotas for July 2009 confirmed that staffing levels had been maintained. With the following staffing levels, and these had not changed since the previous inspection: The care manager is full time, and supernumerary, she is assisted by the deputy manager who is also full time, and hands on, she works some shifts with the care Care Homes for Older People Page 21 of 27 Evidence: staff, and has two days weekly for management related tasks. Langsdale Unit One senior care plus two carers on the early shift. One senior care plus two carers on the late shift. Keswick Unit One senior care plus three carers on the early shift. One senior care plus three carers on the late shift. Overnight there is one senior care plus four carers. The home employs an administrator, domestic staff, a maintenance person, and two activities coordinators. Staff, people spoken with during the inspection visit, and surveys received from people who use the service, confirmed that staff listen and act on what people say, that staff are available when needed. they also confirmed that staffing levels had been maintained. Comments received included staff are very caring and attentive, the staff are always willing to help in any way, they do work hard, we think Sandra and her staff are amazing, and we cannot speak more highly enough of the home and the staff. Staff spoken with confirmed that staff meetings were being held approximately three monthly, and that supervision of staff was being undertaken every eight weeks, as per the National Minimum Standard. They confirmed that they had received updates and refreshers in regard to mandatory training. We were provided with a copy of the staff training matrix, which evidenced and confirmed that care staff had undertaken infection control, first aid, fire, health and safety, dementia care, basic food hygiene, dignity, moving and handling, and abuse training. Other specialist training included the use of the defribillator, epilepsy and diabetes. Four staff recruitment files were examined. These contained all the appropriate security and police checks, and evidenced a good standard of procedures from an administrative point of view. Files were in good order, and uniformly kept. Care Homes for Older People Page 22 of 27 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The management and administration of the home is based on openness and respect, however, quality assurance systems need to be reviewed. Evidence: The Annual Quality Assurance Assessment (AQAA) document, which was completed by the care manager, was returned to the Care Quality Commission CQC on time, and was well completed. The service knows the areas that they want to improve, these included the following: Monthly managers training day at head office. Operations feedback form which is completed and emailed to head office. Policy and procedures have been improved We have reviewed our practices in line with new legislation e.g. Deprivation of Liberty and mental capacity act. We have a 5 day induction programme and the home is committed to having a care team that has a full understanding of the needs of the residents. We listen attentively to the staff and residents and act upon any issues or concerns they have. The AQAA also told us: The registered manager and her deputy Care Homes for Older People Page 23 of 27 Evidence: are dedicated to the home and work in partnership to promote and ensure the home runs well. There are systems in place to assist the manager in the smooth running of the home. The manager empowers the team and leads by example. The home has an IT system which gives them a constant link with head office. A spot check of peoples finances revealed that amounts held by the service on behalf of individuals, tallied with the amounts recorded. Goods purchased on behalf of people using the service were receipted and accounted for. There had been no complaints made to the home since the previous inspection, and one Safeguarding Adult Protection referral had been made to Social Services during that time. Visits under Regulation 26 are undertaken by the organisation, those reports were available for us to view. There is a forum for people using the service to have their say in the general running of the home. However, this should include the setting up of the main menus, the recruitment of staff, and feedback from surveys undertaken by the service. Quality assurance systems should be expanded to include other health professionals. Results from surveys should be collated and feedback to people using the service and staff. Care Homes for Older People Page 24 of 27 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 25 of 27 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 1 8 When a person is being discharged from hospital, the care manager should ensure that the individuals care plan is kept under review, so that staff have up to date and clear instructions, and know how to care for that person. People using the service should be able to have their say about what is on their menu. Shelving should be installed in en-suite bathrooms to enable the safe storage of toiletries. Quality assurance systems should be expanded to include other health professionals. Results from surveys should be collated and feedback to people using the service and staff. 2 3 4 15 24 33 Care Homes for Older People Page 26 of 27 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 27 of 27 - 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!