Inspection on 17/11/05 for Radiant Home

This inspection was carried out on 17th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Radiant Home 11/12/07

Radiant Home 05/07/07

Radiant Home 05/07/06

Radiant Home 03/02/05

Radiant Home 26/08/04

Radiant Home 07/03/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Radiant Home 30 Sextant Road Leicester Leicestershire LE5 2JA Lead Inspector Helen Abel Unannounced Inspection 17th November 2005 08:50 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Radiant Home Address 30 Sextant Road Leicester Leicestershire LE5 2JA Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0116 2419898 Mrs L Hopewell Mr Derrol Paul Hopewell Mr Derrol Paul Hopewell Care Home 6 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (6) of places Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No person who falls within category DE(E) may be admitted to the home when 3 persons who fall within category DE(E) are already acommodated 31st August 2005 Date of last inspection Brief Description of the Service: Radiant House is a small home registered to accommodate up to 6 service users within the category of older people and up to 3 service users within the category of dementia. The home is situated in a residential area with parking available on the street. There are four single en-suite bedrooms on the ground floor and one double en-suite bedroom located on the first floor, which can be accessed by the stair lift. Radiant House has a large lounge with dining area and a sky lounge, known as the sky lounge because it has sky television programmes. There are two fresh water fish tanks and two cats at the home. Both lounges look onto the garden at the rear, which has a lawn and is surrounded by mature plants and shrubs. There is seating for service users and can be accessed by a ramp or steps. Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced during a weekday morning over a four- hour period. A full tour of the building took place with care records, policies and procedures inspected. There was the opportunity to talk with four residents and one visitor. The Registered Manager was present throughout the inspection. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose to be updated and the recent inspection report made available to current and prospective residents. Consider the service received from the Pharmacist and ensure the three monthly inspection visits take place. This will provide residents with a safer service. An improvement to be made to capturing and recording resident’s wishes around death and dying. Establish robust adult protection policies and procedures to safe guard residents. Improve record keeping around staffing rota’s, and staff supervision and recruitment ensuring they are kept up to date and secure. Resident’s rights and best interests should be safeguarded by the home’s record keeping policies and procedures. Develop training programmes around National Vocational Qualifications and other learning for individual staff with an improved staff supervision format. This will ensure staff are trained and competent to do their jobs. Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Assessment procedures are mostly implemented, which ensures that the service meets prospective residents needs. EVIDENCE: Assessment procedures were examined and confirmed residents were admitted only on the basis of a full assessment. Pre- visits were arranged and written information- a Service User Guide is always provided. A Service User Guide is available in the home with pictures and colourful text but requires some updating. A Web site facility is available conforming the service offered. The Registered Manager was unable to locate a copy of the most recent inspection report as part of the required information to be kept in the home. Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9,11 Residents health, personal and social care needs are generally met. EVIDENCE: Care plans were examined and found to hold the appropriate and relevant information. Medicine records were in good order. All staff that administer medication have received insulin and accredited medication training. There had been no visits from the Pharmacist for over a year. The Pharmacist was based outside the immediate area, which sometimes created difficulties when arranging medicines. Regular visits from the Pharmacist must take place with records of advice given. Information around residents death and dying wishes should be sought and be part of the residents individual plan of care. Some evidence of this was taking place with individuals. The Registered Manager agreed the care plan format would be adapted to record and reflect individual’s wishes. Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Meals are flexible to meet the lifestyle of individuals in the home. EVIDENCE: Residents told the Inspector “The meals are okay” “The food is very good” Breakfast was being served at the beginning of the inspection in the lounge, and served individually in resident’s bedrooms. At lunchtime a group of residents sat in the dining room table for a hot lunch. Food was freshly prepared and residents offered choice and variety. A jug of fruit juice was on the dining room table with staff gently encouraging residents to drink throughout the day or offering hot drinks. Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17,18 Resident’s legal rights are protected; but there were shortfalls around protecting adults from abuse. EVIDENCE: The Registered Manager spoke of ensuring all new residents have the appropriate legal paper work that enables them to participate in the voting process. The adult protection policy and procedure could not be located. This information must be in place to safe guard residents. Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,24,25 Residents live in a safe comfortable environment. EVIDENCE: The main lounge was clean, well maintained and furnished with homely fittings and ornaments and a large fish tank. A large homemade calendar and clock was displayed. Colour pictorial signs identify different rooms and aid residents. The home is commended for this initiative. A sky lounge is available for alternative television channels. Some of the residents particularly like watching the weekend sport. A bathroom door lock fitting was in the process of being mended. All other parts of the home were clean, fresh and pleasant. Residents had personalised their rooms with items of furniture and personal effects. A cat roams freely around the home and is popular with residents. Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The deployment of staff and training for staff is poor and does not protect residents EVIDENCE: The staffing rota did not accurately show which staff are on duty at any time. Training programmes for staff were not evident or National Vocational Training Qualification (NVQ) programmes in Care. The minimum ratio of 50 trained care staff in NVQ’s achieved for 2005 had not been met. Staff recruitment files confirmed robust recruitment procedures had not been followed. Staff recruitment files were sampled and a number did not contain the required information. One staff member’s recruitment file could not be located at all. Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,35,36,37,38 There are significant shortfalls with the management and administration systems not fully met. EVIDENCE: The Registered Manager is working towards National Vocational Qualification in Management level 4. He is present in the home working alongside staff on a shift system. Advice was given to the Registered Manager around seeking out good practice, seeking out training resources and making improvements. A visitor confirmed, “ My mother has been at the home for 3 years. She has been supported by the Registered Manager/Registered Provider. My mother is always kept clean and when staff dress her, will make sure her clothes coordinate. I am always made welcome and offered a drink. Staff are very cheerful.” Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 15 Staff are not offered regular formal supervision or an opportunity for an identification of their training needs. It was noted throughout the inspection that redundant paperwork had been kept. Records were frequently not up to date, or accurate and were even difficult for the Registered Manager to locate. Some records were later located at the Registered Managers home. All records relating to the running of the home should be held securely in the home. The health and safety procedures and processes examined were in good order and safeguarded residents. Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 3 2 x x 3 x 3 3 x STAFFING Standard No Score 27 2 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 x 3 x 2 1 3 Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The Statement of Purpose/ Service User Guide must include: The number relevant qualifications and experience of staff; The organisational structure of the home; The number and size of rooms; Whether nursing is to be provided; Policy and procedure for emergency admission; Fire precautions and associated emergency procedures; Arrangements for dealing with reviews of the residents care plan. Timescale for action 01/01/06 2. OP9 13 A copy of the most recent inspection report must be kept in the home The Registered Person shall 01/01/06 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. The Pharmacist must visit at least every three months and records of advice given must be kept. Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 18 3. OP11 12 The Registered Person shall, for the purpose of providing care to residents and making proper provision for their health and welfare, so far as practicable ascertain and take into account their wishes and feelings. Individual’s wishes around death and dying, spiritual needs, rites and functions are recorded in their plan of care. 05/12/05 4. OP18 12 The Registered Person shall ensure that the care is conducted so as to promote and make proper provision for the health and welfare of residents. 05/12/05 5 OP27 18 Ensure robust Adult Protection policies and procedures are in place and reflect good practice around the Department of Health Guidance No Secrets. 17/11/05 The Registered Person must ensure at all times suitably qualified competent and experienced persons are working at the home in such numbers as are appropriate for the health and welfare of residents. A copy of the duty roster of person working at the home, showing which staff are on duty and in what capacity is held. 01/01/06 Ensure that the persons employed by the Registered Person to work at the home receive- training appropriate to the work they are to perform. A training programme for individual staff to be agreed and set up with emphasis on National Vocational Qualifications (NVQ); and a minimum ratio of 50 trained members of staff have an NVQ 2 or equivalent. DS0000006382.V265529.R01.S.doc Version 5.0 Page 19 6 OP28 18 Radiant Home 7 OP29 7 Information and documents in 01/01/06 respect of persons carrying on, managing or working at care home must include: 1. Proof of a person’s identity, including a recent photograph. 2. The person’s birth certificate. 3. The person’s current passport (if any). 4. Two written references relating to the person. The Registered Person shall ensure that persons working at the home are appropriately supervised. The Registered Person shall: 1. Ensure records are kept up to date at all times and available for inspection in the home 2. Ensure records are kept secure. 3. The records shall be retained for not less than three years from the date of the last entry. 05/12/05 8 OP36 18 9 OP37 17 05/12/05 10 OP19 23 To repair bathroom door lock and sliding door to ensure privacy and dignity. This remains outstanding from the last inspection of the 31st August 2005 30/11/05 Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP36 Good Practice Recommendations To contract with a pharmacist within the immediate vicinity of the home and gain a prompt and efficient service. Develop a supervision format that includes the following: 1. All aspects of practice 2. Philosophy of care in the home. 3. Career development needs Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Radiant Home DS0000006382.V265529.R01.S.doc Version 5.0 Page 22 - 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. 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