Care Home: Westcliff Lodge

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What the care home does well The home had a clear sense of direction and leadership. Policies, procedures and guidance had been regularly reviewed which enabled staff to provide a good standard of care. Staff were well trained and supervised. The monitoring and reviewing processes used within the home had provided an established audit tool for both the manager and the owner to use. This meant that should improvements need to be made for the benefit of residents, they are promptly noted and addressed. The established quality assurance processes used within the home had ensured that all stakeholders had been consulted about the provision. We saw that as a result, improvement and changes had been made. These are noted within this report. Residents` families and friends play a very active part within the home. There was a `family orientated` feel in the home. What has improved since the last inspection? The practice of ensuring that residents` views are noted within care plans was established. Medication practices had improved to ensure that processes are safer. The activities programme has been developed. What the care home could do better: The issues we noted within the inspection as requiring review had in the main come to the manager`s attention through the home`s quality monitoring processes. For example, a clearer presentation of details on the resident`s menu would help some residents. There were other matters as noted within the report which the manager had either dealt with before the inspection finished or agreed to address with minimal delay. We felt assured that where development work needed to be carried out for the benefit of residents, it would be achieved as quickly as possible. Key inspection report Care homes for older people Name: Address: Westcliff Lodge 118/120 Crowstone Road Westcliff On Sea Essex SS0 8LQ     The quality rating for this care home is:   three star excellent service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Ann Davey     Date: 0 6 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 28 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 28 Information about the care home Name of care home: Address: Westcliff Lodge 118/120 Crowstone Road Westcliff On Sea Essex SS0 8LQ 01702354718 01702354718 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Westcliff Lodge Limited care home 22 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: Date of last inspection Brief description of the care home Westcliff Lodge is situated in a residential area of Westcliff on Sea. It is located within reasonable walking distance of all local community services and facilities. Westcliff main line railway station and the seafront are close by and Southend on Sea is easily available. Westcliff Lodge is registered to provide personal care for twenty two older people. Some residents have care needs associated with dementia. The accommodation is on two floors with a passenger lift providing access. The home provides eighteen single and two double bedrooms. All bedrooms except for one single, have en-suite facilities. There are two lounges, a dining room, a hairdressing room and a conservatory for residents to use. There is car parking facilities to the front of the building and a pleasant rear garden for residents to use. All prospective residents are provided with a Statement of Purpose and Service User Guide that supplied them with up to date information on the home. Fees range from £395.00 to £550.00 per week and there are additional charges for personal items. The range of fees depends on the Care Homes for Older People Page 4 of 28 Over 65 3 22 0 0 Brief description of the care home accomodation requested or available, assessed care needs and the source of funding. Care Homes for Older People Page 5 of 28 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: The last key inspection took place in this home on 21st June 2007. We carried out an Annual Service Review on 21st May 2008. This key inspection took place over seven and half hours. The visit started at 9.30am and finished at 5pm. The homes manager helped us throughout the inspection. The homes Annual Quality Assurance Assessment (AQAA) which is required by law to be completed by the service had been completed and returned to us within the agreed timescale. The document provided the home with the opportunity of recording what it did well, what it could do better, what had improved in the previous twelve months and its future plans for improving the service. We sent surveys to the home asking that they be distributed and returned to us so that we could have an understanding of how residents, staff, relatives and health/social care professionals felt about the provision. We were assured that completed surveys Care Homes for Older People Page 6 of 28 had been sent to us. Unfortunately we have not been able to locate them. The home had a very comprehensive quality assurance system in place and we utilised this resource. The day spent in the home was pleasant and everybody was helpful. We spoke to residents, staff and visitors. We also gave the visiting community nurse the opportunity to speak with us. We looked around the home and viewed aspects of various records which were selected at random. All matters relating to the outcome of the inspection were discussed with the manager so that where necessary development work could begin. Care Homes for Older People Page 7 of 28 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 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 8 of 28 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 9 of 28 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 needs are fully assessed before admission to make sure that these can be met by the home. Evidence: The homes Brochure and Information Pack were displayed in the main entrance. This document had been reviewed in June 2009 and contained the last inspection report. This means that prospective residents and all interested parties can read about the home and understand what it can offer and provide. Within these documents there were also other items of information and interest. The pre-admission documentation of two residents admitted since the last inspection was viewed. Both had clear and comprehensive details in place. There was a clear process of assessment and review on both files. Care plans for both residents had been put in place. Care Homes for Older People Page 10 of 28 Evidence: Residents and their respective families had been involved in the process. Residents views, wishes, preferences and expectations had been clearly recorded. We took the opportunity to speak to one of the residents who had been admitted. They told us that the experience had been positive and the home had made them feel very welcome. Care Homes for Older People Page 11 of 28 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. Residents health and personal care needs were known to staff and underpinned by a robust recording system. Evidence: Four care plans and associated documentation such as risk assessments and accident records were viewed. Files were well indexed, orderly and easy to follow. Documentation supported that residents and their respective relatives (if appropriate) had been consulted about the care they wished to receive. We noted entries within documents where a resident had been asked about their wishes and preferences and this had been incorporated within the care plan. There were detailed personal risk assessments in place and we saw that individual care plans had been reviewed on a regular basis and updated as necessary. There was a daily record of care on each residents file. The risk assessments, health and incident records we looked at corresponded with the information within respective care plans. Residents told us they look after me here...theres always someone around when I need to go to the toilet...I only have to ask and someone will help me. Residents can Care Homes for Older People Page 12 of 28 Evidence: be confident that their care and health needs are recorded and reviewed on a regular basis. The home had a staff handover book that was used to ensure important information about residents care needs was available for staff as they finished or start their shifts. Whilst we understood the reason and the practicality of such a communal book, residents were identified by name and personal information was recorded. There was a notice displayed in a public area giving residents names and some of their personal details. The manager explained that this information would be useful in the event of a fire and had been acceptable to the previous registration authority. Our view at this inspection was that these specific practices needed to be reviewed because residents personal details were held within a communal document and/or displayed in a public area. Various options of how this useful and helpful information might be managed better was discussed with the manager so that information on individual residents was kept confidential. Staff we spoke with knew about residents current needs. They were able to tell us about individual needs as well as what was required to meet them. We found staff to be knowledgeable about individual residents health care needs. Residents we spoke with indicated that they felt confident that staff knew what their care needs were and how these should be met. We spoke with two visitors who told us that they were very satisfied that their respective relatives needs were known by the home and met well. The manager told us that the home had a good working relationship with all health care professionals. They also reported a good relationship with the various local authorities social care provision. Medicines in the home were administrated by senior staff. We looked at various aspects of the medicines administration recording system, the medicines storage system and the administration process. There were no anomalies within the recording system, the storage system was orderly and staff had current policies and procedures in place to guide and assist them. Where staff had made handwritten entries within the medicine administration records, it is good practice for two members of staff sign these entries to ensure that there are no errors. We reported to the manager that on arrival to the home we noted that the medicines trolley although locked had not been secured to the wall. The manager acknowledged that this was an oversight. The trolley was securely secured to the wall throughout the remainder of the day when not in use. The member of staff who assisted us with the medicines demonstrated competence and knowledge. Care Homes for Older People Page 13 of 28 Evidence: During the day we observed that staff spoke and engaged with residents in a polite, respectful and friendly manner. There were no aspects of care practice that concerned us. We observed the interaction between two members of staff and a resident who was being taken to the hospital for an outpatients appointment. The resident was fully involved in the process and considerable care was being taken by the staff members ensuring that all the paperwork was ready and the resident was comfortable and prepared well for the journey. We observed another incident where a resident was expressing sadness. Staff were not aware of our observations and we noted the sensitivity and supportive manner in which the situation was being managed. Care Homes for Older People Page 14 of 28 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 benefit from a balanced diet and a varied activity, social and occupation programme. Evidence: The home operates a 4 weekly rotation menu. We saw that resident had choice and variety at each meal. We saw a record of what individual residents had chosen for the preceding days. Within the kitchen there was clear guidance about individual residents preferences, special diets and medical requirements. For example, some residents required their medication to be taken on an empty stomach. There were clear instructions about the arrangements at breakfast time to facilitate this. The cook had Food Standard Agency Guidance and Kitchen and Dining Policies to hand and was knowledgeable about infection control when handling and preparing food. The menus for the day were clearly displayed and residents told us that they had been asked about what they wished to have. All those we spoke with were very complementary about the food. On residents individual files we noted current weight record documentation. This ensures that staff monitor the weight of residents enabling them to be proactive should there be a fluctuation. Care Homes for Older People Page 15 of 28 Evidence: The two visitors we spoke with told us that they had also had a meal in the home and found it to be exceedingly good and tasty...a real treat. We did not observe a mealtime within the home on this occasion. The dining room was airy, comfortable and each table had a small plant/flower arrangement on it. The dining room environment was pleasant and homely for residents to enjoy their meals. Residents told us we get a choice here...the food is lovely and so much of it...yes, I can have fresh fruit if I want it...I can eat in my room if I want to, but I like the dining room. The home has a varied and interesting activities programme. The programme for the current month was displayed. There are designated hours for staff to provided focused activities. All residents have family or friends who visit the home regularly. We could see that activities and events are family focused and enjoyed and supported by families. The ethos of the home is to be family orientated and this was supported by the popular weekly fish and chip meal to which all family members are invited, together with outings, BBQs and other events. We could see from the records that activities and events provided by the home are all inclusive and this promotes variety and choice. During the week of the inspection the manager and a member of staff were to attend a course about providing suitable and appropriate activities for residents who have care needs associated with dementia. Residents we spoke with were complementary about the activities provided. Relatives we spoke with confirmed that they are fully involved with the social life of the home.We love it....they do some nice things here were some of the comments we received. Care Homes for Older People Page 16 of 28 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 be confident that any concerns would be managed appropriately and are protected by the homes safeguarding adults from harm procedures. Evidence: The homes complaints procedure was within the Brochure and Information Pack. The manager agreed that it would be good practice to display the procedure on the information notice board. Residents we spoke with said that they would raise any concern with a member of staff, the manager or a relative. All indicated that they would have no hesitancy in raising an issue should it be necessary. All residents have regular visits from either their families or friends and most residents felt that they would probably mention a concern to them first with the expectation that they would deal with it. The two visitors we spoke with were confident that the manager would deal with any complaint or concern in a proper manner. Within the past two years the home had received one formal complaint. This was in respect of a care practice. We saw from the records how the home had managed the concerns and the positive outcome following an investigation.We spoke with a visitor who told us about a concern that had been discussed with the manager and how that had been quickly resolved. The visitor told us that the manager had been quick to respond and the outcome was positive. Care Homes for Older People Page 17 of 28 Evidence: Over the previous two years there had been one safeguarding matter reported to the local authority concerning a care practice. The conclusion was that the matter was not upheld. We looked at the homes safeguarding polices and procedures and felt that some guidance could be misleading. We discussed the matter with the manager who agreed that the particular sentences in question had not been worded clearly which had the potential to be misunderstood. This was with regard to the actions of the manager should an incident be suspected. The manager agreed to review the document to ensure that the sentence in question would be made much clearer. It was interesting to note that information about the homes safeguarding policy and procedure was displayed for relatives and residents to read and know about. We asked four members of staff about their understanding of the terms safeguarding adults from harm and whistle blowing. There were records to support that staff had received training about how to keep residents safe. All demonstrated competence and responded in a manner which was in line with the homes polices and procedures. There was a window cleaner on the premises and we took the opportunity ask them about their actions should they suspect bad practice whilst they were there or in any home they visited. The window cleaner was familiar with the term safeguarding and told us that they knew they had a duty to report such matters. This chance conversation was most encouraging to us. Care Homes for Older People Page 18 of 28 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. Residents live in a clean, comfortable and pleasant environment. Evidence: The main area of the home was of an older style and over the years some more modern and up to date aspects had been added. For example a large conservatory and some of the bedrooms, bathrooms and communal areas have been built or adapted to improve the environment for residents. As with any building of this size there was a continuing programme of repair, maintenance and decoration. Some areas and aspects of the home were in keeping with its age whilst others had a more modern feel about them. The areas we looked around were in good repair with pleasant decor and furnishings. The communal areas were comfortable and airy. Bedrooms were personalised and furnished in keeping with the occupants personalised taste. Bathrooms, shower rooms and toilets were functional and practicable. We noted that there were no locks on the toilet and bathroom doors but there was a polite notice on the doors asking please knock before entering. The main entrance hall way had a comfortable small seating area with plenty of interesting information on display. The kitchen and laundry area were clean and orderly. The area behind the washing machine and tumble dryer required deep Care Homes for Older People Page 19 of 28 Evidence: cleaning as there was a potential fire risk from the items that had accumulated. We were confident that the manager was to action this without delay. There were no unpleasant odours anywhere in the home. Residents had direct access to a well maintained secure rear garden area. There was also an attractive furnished patio area to the side of the home. Residents we spoke with told us that they particularly enjoy sitting in this area and thought that the tables, chairs and umbrellas were very nice. Other residents told us my room is nice and I can see the sea...I have a comfortable chair...its been hot here, but they are very good and moved us to somewhere more comfortable, we got plenty of drinks to help us. The home is registered to provide care for residents who have needs associated with dementia. We noted that the door to the laundry area could not be locked because it is a fire escape route. This area housed electrical equipment and chemical clothes washing liquid and potentially there was a risk to these residents should they go into this area unsupervised. We also saw boxes of latex gloves around the home which could be picked up by residents and used inappropriately. The manager agreed to review these practices to ensure that all residents are kept safe. We noted that by the afternoon of our visit, the boxes of gloves had been removed and options were being considered with regard to the laundry door. Communal rooms had pictorial signs on the doors to tell residents what the room is used for and the manager reported that the home will improve the directional signage within the premises to assist residents who may have difficulty with orientation around the home. Care Homes for Older People Page 20 of 28 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. Residents are cared for by a team of staff who had been well recruited, trained and supervised. Evidence: The home was registered to provide care for twenty two residents. On the day of the inspection, nineteen residents were accommodated. The outcome for this group of standards had been based on the staffing arrangements for nineteen residents. The manager reported to us that they work in a managerial capacity Monday to Friday 9am - 5pm (approximately). Care is provided by a minimum of 2 carers and a senior carer during the day and a senior carer and a carer at night. There was a team of housekeeping, cooking and maintenance staff. The staff rota was available and reflected the staff on duty. We were informed that there were no staff vacancies and the home does not use agency staff. The manager reported that staff sickness was relatively low, morale was good, the team of staff were very reliable and the core group of staff had worked in the home for some time. The outcome for residents meant that they were cared for by a team of staff who are consistent. We saw a list of the forthcoming staff training sessions and a comprehensive records Care Homes for Older People Page 21 of 28 Evidence: were available to demonstrate what courses staff had already attended. Members of staff reported that they have access to good training opportunities, receive regular supervision from the manager and are expected to attend the planned team meetings. One member of staff told us Ive had lots of training but I then have to do a test to make sure I know it....we all do that. Staff looked very smart in their clean and practical uniform style dress. Staff told us that in their opinion sufficient staff were on duty at all times to meet residents needs. This view was also expressed by the visitors we spoke with. We looked at the recruitment records of two members of staff who had started work in the home since the last inspection. The elements we looked at met regulatory requirements. The manager reported to us that three members of staff had completed their NVQ level 3, with another three in the process of completing the course. There were five members of staff currently undertaking the NVQ level 2 course with a further one booked to undertake it in the near future. The AQAA stated approximately 83 of care staff are undertaking an NVQ qualification or have been enrolled and are waiting to commence. This achievement was assessed by us as good and of benefit to residents. Care Homes for Older People Page 22 of 28 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. Residents live in a home where the day to day management promotes excellent outcomes for residents. Evidence: The manager had a Registered Managers Award and a NVQ level 4 qualification. The manager was able to demonstrate that they update their own training on a regular basis. For example, they had booked to attend a course about the Mental Health Act 2005 and the recent Deprivation of Liberty Safeguards legislation. The owner of the home had visited the home on a regular basis. We saw records to demonstrate that these visits were detailed and comprehensive. This means that the owner had a regular overview of how the home had being managed on a day to day basis. The home had a current environmental and safe working assessment folder in place. Around the home we saw health and safety notices in place. There were current Care Homes for Older People Page 23 of 28 Evidence: COSHH (Control of Substances Hazardous to Health) data sheets in place. Infection control information and guidance had been displayed in appropriate places. We sampled service contracts and maintenance agreement documentation and noted they were current. The homes policies, procedures, information and guidance documentation system was well indexed and current. We were shown the daily, monthly and annual management review and monitoring tools used by the manager to ensure that standards within the home are maintained to a good standard. Where shortfalls in any aspect of care had been noted by the manager, we could see where these had been addressed with promptly. The office area was orderly, files were well indexed and available, information, polices and procedures were current and accessible to staff. Residents and their respective families had played an active part in the day to day management of the home. Their views, opinions and views had been sought through the established quality monitoring process and the regular resident/relative meetings. We saw that as a result of these regular consultations, changes where needed and practicable, had been made for the benefit of residents. For example, residents had been involved in choosing the colour scheme during the recent decoration programme, signage around the home had improved, agency staff are no longer employed and each resident had been given their own Brochure and Information Pack. There was an Annual Development Plan dated March 2009 in place. There were full details of how the review of care had been undertaken including a breakdown of all the stakeholders surveys responses. The Fire and Rescue Service and the Environmental Health Department had undertaken satisfactory visits to the home in September 2008 and March 2009 respectively. During our visit, a representative from the fire alarm company arrived to undertake a routine service. The home looked after residents personal monies if requested. We saw a file which contained full details of all financial transactions made on behalf of residents. Receipts for all expenditure were available. We noted that the system was audited by the owner. There was clear sense of leadership, direction and management within the home. Staff were clear about their duties and responsibilities. We spoke to staff about the management style within the home and how it had enabled them to provide a good standard of care. We received the following comments (Stephanie) is so Care Homes for Older People Page 24 of 28 Evidence: supportive...she shows us how to do the right things and then we have supervision to make sure weve got it right...(Stephanie) has high standards but shes very approachable...(Stephanie) works with us, shes a lovely person...we all like her...shes a good manager and very fair....residents are important to her. Within the AQAA the following comments were noted as a team we feel an enormous sense of pride in our achievements and how the team has developed. We accept we do not always succeed and we are open to mistakes and we always endeavour to act promptly to put things right. Quality care is our focus and priority. As a result of this inspection we would support the managers assessment of the home. Care Homes for Older People Page 25 of 28 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 26 of 28 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 7 Further consideration should be given to where residents personal information is held to ensure confidentiality is maintained Where staff make handwritten entries within the medication administration records, it is good practice for these entries to be checked and signed by two members of staff to prevent any error. 2 9 Care Homes for Older People Page 27 of 28 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). 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