Care Home: WCC Mayfield

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What the care home does well Pre admission documentation available within the care plans looked at confirmed that the manager of the service was satisfied that the home would be able to meet peoples care and support needs prior to them moving in. Care planning documentation is comprehensive and detailed, and also includes pertinent risk assessments. All of this information is reviewed regularly and updated as necessary to ensure that the staff have the most current information to work from. Medication policies and procedures in place ensure that this is managed safely on peoples` behalf. Relatives are free to visit the home at any time and are made welcome by friendly and courteous staff. People are offered a variety of activities throughout the week that are planned and coordinated by the homes activities person. Meals are wholesome, nutritious, tasty, and enjoyed by the residents. Residents and relatives can be sure that any concerns or complaints that they have will be treated sensitively and resolved as far as possible. The homes policies on complaints and protection from abuse safeguard the residents, as does the homes staff recruitment procedures. The environment is comfortable, homely, hygienic, clean and tidy, and is appreciated by both residents and visitors alike. An annual quality survey ensures that residents views are listened to and kept at the forefront of service delivery. Health and safety is managed well. What has improved since the last inspection? One requirement was made at the last inspection of this home which pertained to risk assessments for the use of bed rails. This requirement has been met by the manager and staff and good examples were seen in peoples` care plan files. What the care home could do better: No requirements have been generated as a result of this inspection visit. Two good practice recommendations pertaining to training of staff have been made. Key inspection report Care homes for older people Name: Address: WCC Mayfield Mayfield Close Bedworth CV12 8ES     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: Justine Poulton     Date: 2 8 0 1 2 0 1 0 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 29 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) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: WCC Mayfield Mayfield Close Bedworth CV12 8ES 02476313600 02476315376 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Warwickshire County Council, Adult Health & Community Services Name of registered manager (if applicable) Mrs Dawn Johnson Type of registration: Number of places registered: care home 35 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: 35 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) 35 Date of last inspection Brief description of the care home Mayfield is a Local Authority home for older people. It currently has with thirty-five beds, however it is intended that this will be reduced to twenty in the near future. It provides permanent care, short stay (respite) and day care. The home is situated on a housing estate, within easy walking distance of Bedworth town centre. The town is a small but busy community, with a variety of shops, a local Care Homes for Older People Page 4 of 29 1 9 1 2 2 0 0 8 0 Over 65 35 Brief description of the care home market and a civic centre. These are all in a pedestrian zone. The home is close to local bus routes as well as being provided with services from Coventry and Nuneaton. It is also close to the M6 motorway. There is car parking to the front and rear of the home. Accomodation is to be provided on the first floor of the home. The ground floor bedroom and lounge accomodation is to be closed for the foreseeable future. There is one lounge in use and a main dining area. There is a day care area with its own lounge with kitchenette, which does not have to be registered and therefore was not inspected. All bedrooms have en-suite toilets and washbasin, and on each floor there are bathrooms and toilets suitable for people who need assistance. The main kitchen, laundry and staff offices are on the ground floor. Access to the upper floors is via either of the two staircases or the passenger lift. The fees are social services rates and depend on the persons financial standing. Additional charges are made for hairdressing, chiropody, day trips, toiletries and entrance fees whilst on outings. Care Homes for Older People Page 5 of 29 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 inspection was carried out to establish the outcomes for people living in this home, and to confirm whether they are protected from harm. Identified key standards were looked at, along with a review of the organisations progress towards meeting any requirements made at the previous inspection of this service. The pre fieldwork inspection record was completed, as well as a site visit to the home, during which time staff, people living in the home, relatives, and the manager were spoken with. A completed annual quality assurance assessment was received from the service prior to the inspection. We also received twenty completed surveys. Two people were identified for close examination by reading their care plans, risk assessments, daily records and other relevant information. This is part of a process Care Homes for Older People Page 6 of 29 known as case tracking where evidence is matched to outcomes for residents. Records, policies and procedures were examined and the environment was looked at. Care Homes for Older People Page 7 of 29 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 Care Homes for Older People Page 8 of 29 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 29 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 29 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. Prospective residents can be confident that their assessed needs will be met by the home should they decide to move in. Evidence: The home adheres to the local authority admission policy and procedures. The AQAA states that the home undertakes A thorough approach to pre-admission assessment to ensure that needs can adequately be met. Two people who have recently moved into the home were chosen for case tracking purposes. We examined their care plan files to assess the pre admission assessment process. We saw a completed Social Services Assessment of Need in both care plans we looked at. This confirmed that pre admission information is obtained by the home prior to Care Homes for Older People Page 11 of 29 Evidence: people moving in. In addition we saw a completed Adult Health and Community Services Assessment and Capacity to Meet Need form in one file. Information contained within these assessments included the proposed reason for admission and principle diagnosis of the person. We spoke to staff who told us that prior to moving into the home people are invited to visit and look around with their relatives or friends. One person we spoke to confirmed that they had been able to visit the home before they chose to move in. The home does not provide intermediate care. Care Homes for Older People Page 12 of 29 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. People living in this home can be confident that comprehensive, detailed care plans and risk assessments ensure that their well being and safety are promoted. People can be confident that their medication is managed safely on their behalf. Evidence: Both people chosen for case tracking purposes had care plans, risk assessments and key support records in place. These were all looked at to determine whether and how their assessed needs were being met. They contained satisfactory levels of information which informed staff about what support was needed and how they were expected to provide it for people. The care plans covered areas of care and support which included personal needs and preferences; daily routines; personal care guidance and prompts. For example in one plan looked at it clearly records that the person does not want a male carer to assist with personal care. We followed this up with a staff member who confirmed that the current staff team is made up of female personnel. Other areas covered by care plans included any equipment used such as a hearing aid or glasses X wears glasses at all times... and will require assistance with cleaning them. When we met this person during the inspection visit we noted that she was wearing glasses, Care Homes for Older People Page 13 of 29 Evidence: and we asked her if the staff helped with keeping them clean and in good order. She told us that the staff clean my glasses for me every morning. In addition to the care plans in place each person case tracked also had a number of risk assessments mainly covering their heath needs. Current moving and handling assessments were in place accompanied by a mobility plan where applicable, as well as assessments covering falls management, nutrition and hydration, the use of bed rails and pressure area and skin viability amongst others. The information contained within the risk assessments in place was detailed and clearly informed staff of the action to be taken to ensure that the risk was minimised. Records of review dates and any amendments made were also in place, and confirmed that they had all been reviewed within the last six months. The AQAA tells us that The GP visits the home on a weekly basis for routine health issues and will also be called in when necessary. Community nurses, chiropodist, optician, occupational and physiotherapist and dentist regularly visit to provide health support for the service users. Information available in the care plan files that we looked at confirmed that people are supported to maintain their health and well being in line with this statement. During the inspection visit a GP visited the home. We saw that he attended to his patients in the privacy of their own bedrooms, and staff recorded the outcome of his visit in the relevant care plans. The AQAA tells us that Medication administration and management has been the focus of our attention. Staff now administer medication in pairs which speeds up the process and improve accuracy. We audit frequently. Medication is stored within the home in locked trolleys which are located in a lockable walk in cupboards. Medication is supplied to the home by a local pharmacy accompanied by medication administration record (MAR) charts. A photograph of each person was available with their MAR chart to assist with ensuring that medications are administered to the correct person. The medications and MAR charts of the people chosen for case tracking purposes were looked at and did not provide any cause for concern at the time of the inspection. We were told that the home was in the process of implementing new as and when protocols for homely remedy medications that are not prescribed. We were told that these were not going to be signed off by a GP. This was discussed with the manager as best practice would indicate that it would be advisable for a GP to approve these protocols to confirm that any homely remedy administered to people would not interact with prescribed medication detrimentally. At the previous inspection of this service concern was raised about the temperature of these walk in cupboards and the effects that excessive heat could have on some Care Homes for Older People Page 14 of 29 Evidence: medications. This has since been addressed, and the temperatures are monitored daily. Care Homes for Older People Page 15 of 29 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. A variety of activities are available for people to choose from if they so wish. Peoples relationships with families and friends are promoted and encouraged and they are made to feel welcome in the home. People can be confident that a healthy, nutritious diet is provided. Evidence: The home employs an activities coordinator to plan activities that are appropriate to peoples needs, and that take into account peoples interests and hobbies. We spoke to the activities coordinator who told us that she is responsible for scheduling, organising and delivering activities for people living in the home. She also told us that she runs the shop and coordinates the monthly residents meetings. The home has a dedicated activities budget. We were told that this appears to be sufficient to cover the cost of all activities considered. There is a plan of regular activities that take place on a weekly or monthly basis. These include Creative Mobility sessions, one of which was taking place during this visit and was very well attended, dance zone, pat a dog and a monthly church service. In addition activities such as a coffee morning, life story sessions, target games, lunch out, bingo, visits to the cinema and memory box sessions are offerd. A canal boat trip has also been planned for April. Weekly activities programmes are displayed around the home so that people are aware of what is Care Homes for Older People Page 16 of 29 Evidence: available. We spoke to a number of people who live in the home about the activities available. They were all very complimentary about the activities coordinator, and said that they enjoyed the opportunities to participate in things that were available for them... I enjoy the exercises with Tim...; we have regular coffee mornings that are nice; I like to see the dog.... As well as the activities programmes, an individual record of activities participated in or declined is maintained. We spoke to one person who we were told chooses not to participate in planned activities. He told us that he doesnt like to join in with these, but was very pleased that he had been provided with some models of a car and an engine to build, in keeping with his interests and former working life. Continued contact with families and friends is seen as being of paramount importance for the people living in the home. As such the manager and staff strive to ensure that people are supported with this as they wish. A policy pertaining to contact with family and friends is available, and is provided to families when their relative moves into the home. People are free to receive visitors at any reasonable time, and they can see them in either private or more communal areas as they so choose. A number of visitors were seen to come and go during the inspection visit. We spoke to two visitors during our visit, both of whom were very complimentary about the care and service their relatives or friends were receiving, Mum is looked after really well, I visit most days and she always seems happy and well cared for; Hes really doing well since moving in here. As part of our inspection visit we had a look at the kitchen, which was impeccably clean and well ordered. There were plentiful stocks of high quality branded processed foods in place as well as plenty of fresh and frozen foods. All records required under food safety and hygiene were in place and up to date, including a record of food temperatures upon delivery of all fresh meats and frozen foods, fridge and freezer temperature records and a cleaning schedule. The dining room was spacious, light and airy, with dining tables and seating that enabled people to sit where they chose, with whom they chose. The dining tables were nicely laid and appropriate condiments were available. People were individually offered a choice of meals and drinks. The food available was plentiful and nicely presented. We had lunch with two people who live in the home, both of whom were complimentary of the meals, The food is nice and theres always plenty of it, I like the choices were offered and there are always alternatives if we dont like what is available, the food is good, I need new clothes because Ive put on weight. We saw people being offered alternatives of soup or sandwiches if it appeared that they did not like the meal they had originally chosen. Care Homes for Older People Page 17 of 29 Evidence: Facility for people to take their meals in their bedrooms is available should they wish to. Specialist diets such as diabetic, or vegetarian are accommodated. Care Homes for Older People Page 18 of 29 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 people living in this home can be confident that the homes policies on complaints and protection from abuse ensure that their views are listened to and acted upon, and that they are safeguarded from harm. Evidence: The home adheres to the local authority comments, compliments and complaints procedures. The AQAA tells us that The improving culture and increasing openness of the home is developing early expression of choice or concern. This in itself reduces significantly the rise of getting things wrong and creating possible cause for complaint. The AQAA also tells us that the home has not received any complaints since the last inspection. We looked at the complaints log. There were no complaints recorded. We did see record of a number of compliments, such as a big thank you to you all for making Mums stay at Mayfield a happy one; A very big thank you for all your care and compassion during my time here. We spoke to three people who live in the home about whether they were aware of how to make a complaint should they need to. All three were confident that they would never need to and told us that they would talk to a staff member or the manager is necessary. One relative we spoke to told us that she has no complaints about Mums care, but I would talk to the manager of necessary. There is a box located in the entrance hall for anonymous comments, or complaints that is checked on a daily basis. Care Homes for Older People Page 19 of 29 Evidence: As well as the complaints policy the home also adheres to the local authority joint protocols on safeguarding vulnerable adults. The AQAA tells us that one safeguarding referral that generated investigation was made during the last twelve months. Training records looked at told us that seven staff have received training in safeguarding vulnerable adults within the last three years. The records seen indicated that a considerable number of staff have not received any training in this area and the remaining staff received training over four years ago. Although this apparent lack of training leaves people vulnerable to abuse, staff spoken with were able to say what they thought abuse was and how they would deal with it if ever it was suspected, disclosed or witnessed. Care Homes for Older People Page 20 of 29 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. People benefit from a homely, clean and well-maintained environment, which they value. Evidence: The home is currently registered for 35 people. The manager told us that due to the high level of vacancies the home has at the present time, this is being reduced to 20 beds, 18 of which will be for permanent residents, and two will be respite beds. This will result in the whole downstairs wing being closed for the foreseeable future. The AQAA tells us that We provide an environment which enables residents to make the choice between living a private life or one that is socially integrated with others. The entrance to the home has been decorated during the previous 12 months and was bright, airy and welcoming for guests. Communal space in the upstairs wing was nicely decorated with good quality soft furnishings and furniture. A selection of bedrooms were looked at with peoples permission. These were all decorated to a high standard with personalisation and furniture making each room individual to the person it belonged to. The AQAA also tells us We have produced a source of music in the dining room and new aquarium in response to resident wishes. By changing the lighting in lounges and corridors, this has resulted in significant improvement and has been well received by service users. We have responded to resident wishes and created a cinema for residents. We have addressed the issue of offensive odours in Care Homes for Older People Page 21 of 29 Evidence: the home. All of these enhancements have served to enhance the environment for people, who were appreciative of and valued where they live. One person told us that I like to look at the fish as I walk by, they are very relaxing. The laundry area is away from the main body of the home. On the day of our visit, this area was tidy and clean with dedicated areas for each persons clean clothes once they have been washed and ironed prior to them being returned to the individual concerned. Comments about the environment in the surveys we received included the home is always clean and smells nice; decor is good; the home is clean and I always have a clean bed. Care Homes for Older People Page 22 of 29 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 people living in this home benefit from properly recruited sufficient numbers of competent and knowledgeable staff. Evidence: The AQAA tells us that the home employs two full time carers, nineteen part time carers and eighteen part time ancillary staff as well as the registered manager. It also tells us that seventeen of the permanent care staff have achieved their NVQ level 2 or above in care or health and social care. Duty rosters looked at during this inspection visit indicated that there are generally five care staff on duty in the morning and four in the afternoon, with two staff over night. Staff spoken to said that the staff numbers were satisfactory to meet peoples care and support needs at the present time, however, there were comments in the surveys we received that indicated that staffing was not always at adequate levels, for example the home could have more staff and not use agency workers...; we need more staff and residents to make the home work to protect the life and soul of this home; staffing levels at Mayfield are a regular issue, sometimes there are not enough staff for the residents to be safe and staff are working long hours.... The manager told us in discussion about how she is planning to change the staff roster in consultation with the staff, to address staffing issues and meet the needs of the people living in the home more effectively. Two staff files were checked to determine the robustness of the homes staff Care Homes for Older People Page 23 of 29 Evidence: recruitment procedures. Both files contained evidence to indicate that Criminal Record Bureau (CRB) checks had been sought and were awaited along with two written references, a full employment history and proof of identity to ensure that any risks to vulnerable adults is minimised. We were told that both of these people would not be commencing work until a satisfactory CRB check had been received. he AQAA tells us that We exceed the minimum standard for numbers of NVQ2 trained staff and with the Work Force Development Team, we offer an extensive range of training to all staff. All new staff are provided with an induction programme upon commencement of employment. Staff spoken with told us that they are provided with training in the mandatory areas of food hygiene, first aid, fire safety and moving and handling however a number of the training records we looked at had considerable gaps in them indicating that staff either had not received training, or had not received regular refreshers. Regular training in the above mentioned mandatory areas ensures that staff have the knowledge and skills necessary to provide care and support safely to the people living in the home. In addition training records told us that staff have been provided with training in non mandatory areas such as medication administration, health and safety, dementia awareness, mental capacity act, equality and diversity and Parkinsons disease. Care Homes for Older People Page 24 of 29 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. People living in this home benefit from good management systems. Peoples views are sought via an effective quality monitoring system which ensures that their views are at the forefront of service development. People can be confident that that they are safe via effective health and safety management. Evidence: The home is managed by a competent, experienced and suitably qualified manager who is supported by five similarly competent and experienced Senior care staff. An open door style of management was apparent, and both staff and the people living in the home appeared comfortable and at ease in approaching any member of the management team. The AQAA tells us that We operate a Quality Assurance System, which ensures continuous improvement and which is informed by feedback from service users and their families. We undertake regular audits of this system to maintain its Care Homes for Older People Page 25 of 29 Evidence: effectiveness. An annual service user satisfaction survey is undertaken which ensures that we remain aware of any concerns otherwise not addressed. The manager told us that this process is mainly undertaken via staff in Shire Hall, and the outcome is then sent to the home complete with an action plan for service improvement and development. We did not see the results of the most recent quality audit undertaken during this visit. Information in the AQAA records that all of the necessary routine health and safety monitoring and checks are in place and up to date. A sample of these which included the landlords gas certificate, fire alarm testing, hot water testing, portable appliance testing and lift servicing confirmed this. A health and safety policy is in place, and staff are provided with health and safety training. Cleaning materials are stored safely and associated control of substances hazardous to health (coshh) data sheets are in place, which ensures that everyone that lives in, works in or visits the home can be confident that they are as safe as practicably possible. Care Homes for Older People Page 26 of 29 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 27 of 29 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 18 Staff should be offered training or refreshers in safeguarding vulnerable adults to ensure that they have current knowledge and work to best practice, thus ensuring that people are protected from potential harm. All staff should attend regular training or updates in mandatory training such as basic first aid, fire safety and moving and handling so that people using the service can be confident that they have the skills and knowledge to support them in a safe and appropriate manner. 2 30 Care Homes for Older People Page 28 of 29 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. 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