Inspection on 18/01/06 for Red House

This inspection was carried out on 18th January 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Red House 23/07/07

Red House 09/08/06

Red House 13/07/05

Red House 03/11/04

Red House 03/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Red House Gas House Lane Main Street High Bentham North Yorkshire LA2 7HQ Lead Inspector Mrs Maggie Coxon Unannounced Inspection 18th January 2006 10:15a Red House DS0000007899.V276197.R01.S.doc Version 5.1 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 Red House DS0000007899.V276197.R01.S.doc Version 5.1 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 Adults 18-65. 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. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Red House Address Gas House Lane Main Street High Bentham North Yorkshire LA2 7HQ 01524 262694 01524 262694 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) St Anne`s Community Services Paul Leslie Danvers Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for 5 service users with learning disabilities, some of whom may have physical disabilities, all of whom may also be aged 65 years or older. The home may not admit any service user within the service user category (LD(E)). This category applies to those service users currently in receipt of services. 13th July 2005 Date of last inspection Brief Description of the Service: Red House is a care home registered by St. Annes Community Services to provide personal care and accommodation for up to five adults with learning disabilities some of whom may have physical disabilities and all of whom may be aged 65 years or older. The home consists of a two storey detached house situated on a quiet lane in the market town of High Bentham. The town centre is within easy walking distance of the home and has numerous and varied facilities including shops, cafes, churches and pubs. All five bedrooms are for single accommodation, none of which has en-suite facilities. Shared areas consist of a kitchen, dining room and lounge. The home has a large, landscaped garden that is well maintained. There is hard standing for resident parking in an area close to the home. There is level and ramped access to the home. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second to be undertaken between April 2005 and March 2006. It was done on 18th January 2006, at a time when most of the people living in the home would be present. It took 2.75 hours plus 1 hour’s preparation time. Any key standards not assessed during this inspection have been assessed at the last inspection and reported on in the subsequently published report. Discussions were held with three of the four people currently living in the home and with care staff on duty who assisted with the inspection in the absence of the registered manager. A number of records and most areas of the home, including bedrooms and shared areas, were seen. The registered manager was able to provide some information required by telephone some days later. What the service does well: What has improved since the last inspection? Mr Danvers has had his application to become registered manager approved. A CRB and POVA check has been undertaken in respect on one staff member. One bedroom and an area of the lounge have been redecorated. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 6 What they could do better: 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. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Any prospective resident can be assured, prior to admission, that the home is able to meet his or her needs. EVIDENCE: No recent admissions have taken place. The last resident to move in however, had a reliable assessment of his needs undertaken and from this it was decided that the placement would be appropriate and in the best interest of the individual. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7. People living in the home make as many decisions about and choice in their personal lives and in the day-to-day running of the home as possible. EVIDENCE: Every resident has a care management care plan in place and a personal profile developed by the home that describes his strengths and needs and informs how these needs are to be met. One of the support workers said that some profiles had recently been reviewed by the registered manager and key workers. The profile of one resident however had not been reviewed since February 2005 and a review is now overdue. Residents attend activities of their own choosing with the support from the staff team as and when needed. They make as many decisions and choices for themselves as possible and are as involved in the running of the home as much as they choose to be and are able to be. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 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. Residents enjoy a wide choice of home cooked, good quality food. EVIDENCE: Residents enjoy a very relaxed lifestyle in the home and are consulted about and offered a choice of meals. Residents are encouraged to follow a healthy diet and the meals provided are well balanced and nutritious. A record of all meals eaten is maintained. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. Residents’ personal and health care needs are fully met. EVIDENCE: None of the residents is able to take their own medication. There is a monitored dosage system in operation, which is securely stored. Medication administration records are well maintained and all staff have undertaken appropriate medication training. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Residents’ concerns are appropriately dealt with and their interests are safeguarded. EVIDENCE: There is a comprehensive complaints procedure in operation that is available in various formats and is made available to anyone who wishes to see it. Whilst it is unlikely that a number of the residents would use the formal procedure, each can make any dissatisfaction known to staff who attempt to address any issues promptly and appropriately. Staff have developed very good relationships with the residents and communicate extremely well with them. No complaints have been made to the home or to the C.S.C.I. within the last twelve months. Comprehensive adult protection policies are in place and all staff have adult protection training initially as part of their induction and foundation training then as part of their NVQ. St Annes Community Services also provides a rolling in-house training programme. Staff have a good understanding of the procedure to be followed in the event of or following an allegation of abuse having taken place. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,28,29 and 30. The standard of the environment is good and provides residents with a safe, comfortable and clean place in which to live. EVIDENCE: The home is well maintained and pleasantly decorated and furnished throughout. Shared areas consist of a kitchen, dining room and lounge that has ramped access to a large garden. All five bedrooms are for single accommodation two on the ground floor three on the first. All are of a suitable size. They are all very pleasantly decorated and furnished in line with the taste of the individual. There is a bathroom on both floors; that on the ground floor has an assisted bath, the first floor bathroom has a walk in shower. None of the bedrooms has en suite facilities. Appropriate aids and adaptations are fitted throughout the home and there is level and ramped access to the home. A good standard of cleanliness is maintained throughout. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33 and 34. The residents receive a good standard of care from a highly skilled and motivated staff team. EVIDENCE: Generally speaking, appropriate recruitment procedures are adopted by St Annes Community Services. It had been previously noted that there had been no CRB check in place for the deputy manager, this has since been undertaken. It had also been noted that several CRB checks recently undertaken by the organization had not had the staff member concerned checked against the POVA list and that this could compromise the safety and wellbeing of residents. POVA checks have since been undertaken on most of these individuals but not all. The registered manager said that he would address this shortfall forthwith. A number of the care staff are working towards achieving NVQs in care to level 2 or above. Whilst none has yet completed their awards, several are close to doing so. The support worker who is a work-based assessor explained that she is to attend an assessors’ meeting in February to discuss the new awards. The home currently has a temporary shortfall of 37hours. The staffing roster for the week including the inspection shows that staff are employed in sufficient numbers and are deployed in such a way as to ensure that the needs of people living in the home are met at all times. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. The residents benefit from a well managed home in which their needs and wishes are put first. The fire safety system could however be improved. EVIDENCE: Mr Paul Danvers has been registered by the Commission for Social Care Inspection as the registered manager of Red house. He has completed the registered managers award and is due to commence the NVQ in care to level 4 on completion of which he will be appropriately qualified for his role. St Anne’s Community Services has a quality assurance and monitoring system that includes regular unannounced inspections of the service by a service manager. The reports from these inspections are fed back into the overall quality assurance system. The registered manager has discussed the use of surveys with the staff team during a recent staff meeting and a questionnaire has been produced. Visiting health care professionals and any other callers are offered a questionnaire to complete during their visit. Any comments returned are then shared with the staff team and an action plan devised where needed. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 16 All health and safety systems are being regularly checked and staff are being appropriately trained. All accidents are well recorded. Whilst regular checks of the fire system are being undertaken and staff are having regular training it was noted that the last fire drill was carried out in April 2005. Fire drills should be carried out every six months. Whilst St Annes Community Services has undertaken a check of the hot water storage system in respect of the prevention of Legionella; measures have yet to be taken to ensure that it is stored at a minimum of 60° Celsius. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 1 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 2 X 3 X X 2 X Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 18 Yes Are there any outstanding requirements from the last inspection? 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 YA34 Regulation 19 Requirement POVA checks must be undertaken on those staff for whom CRB certificates have been obtained but a check against the POVA list has not been sought. (This requirement remains outstanding from a previous report). Timescale for action 28/02/06 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. 3. 4. Refer to Standard YA6 YA32 YA37 YA42 Good Practice Recommendations Individual personal profiles should be reviewed at least every six months. A minimum of 50 of care staff should be qualified to NVQ level 2 or above. The Registered Manager should complete an appropriate management qualification. Hot water should be stored at a temperature that safeguards against Legionella (at a minimum of 60° Celsius). Fire drills should be carried out every six months. Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Red House DS0000007899.V276197.R01.S.doc Version 5.1 Page 20 - 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. 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