Inspection on 11/04/05 for Red House Residential Home

This inspection was carried out on 11th April 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

Red House Residential Home 04/06/08

Red House Residential Home 06/06/07

Red House Residential Home 15/06/06

Red House Residential Home 03/02/06

Red House Residential Home 15/11/04

Red House Residential Home 14/04/04

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

CARE HOMES FOR OLDER PEOPLE Red House Residential Home - 236 Dunchurch Road Rugby Warwickshire CV22 6HS Lead Inspector Suzette Farrelly Unannounced 11 April 2005 08:45 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 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. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Red House Residential Home Address 236 Dunchurch Road Rugby Warwickshire CV22 6HS 01788 817255 01788 521263 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Pinnacle Care Ltd PC 23 Category(ies) of DE(E) 23 registration, with number of places Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: No wheelchair users are to be accommodated in rooms 19, 20 and 21. Date of last inspection 15 November 2004 Brief Description of the Service: The Red House Care Home is located approximately one mile from Rugby town centre. It is a converted detached domestic dwelling set back off the main Dunchurch Road. It provides long-term residential care without nursing for twenty-two frail older people and one younger adult, (under 65years of age) including dementia care. Service users who require nursing attention receive this from the Community nursing service, as they would in their own homes. Accommodation is provided on two floors and consists of seventeen single and three double rooms. En-suite facilities are available in some bedrooms there are also two assisted baths and four communal toilets. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over seven hours and is the first of two inspections to be conducted this year. A tour of the premises was undertaken, looking at all communal areas, bedrooms and service areas, such as the kitchen, lounges and bedrooms. Four residents’ care profiles were examined which gave an overview of the care prescribed and delivered, these records also contained information concerning the administration of finances and personal monies of the residents. Records related to staff recruitment, supervision and training were examined along with records related to the upkeep and maintenance of the home. Medication administration and records related to this area were also seen. Four staff and seven residents were spoken to no relatives were seen. What the service does well: What has improved since the last inspection? The home has made improvements in the records maintained for the administration of medication and this process is now acceptable. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 6 Staff have received training in dementia care and a further three staff have started their NVQ training in care. What they could do better: The general cleanliness of the home requires attention; various areas are untidy, disorganised and unclean. The laundry area is very small and very disorganised; the staff must keep this area tidy. The main boiler is also in this area and the provider must consider if the laundry could be moved to a more suitable area. The flooring is not suitable and requires attention and the domestic staff must be able to wash the walls. Information related to the residents and the maintenance of equipment in the home is disorganised and not easy to find. The management must make sure that these are organised to assist the staff in their daily work. Plans of care are written for all residents, these are not detailed enough and further information and guidance is needed to ensure that the staff have direction in the care to be given. The care prescribed must be evaluated each month and changes to care needs clearly indicated, where appropriate changes to the written care plans must be carried out. Policies and procedures related to the prevention, recognition of abuse and vulnerable adults are not complete, this has been required for 12 months, and these are necessary to ensure that there is a reduced risk in abuse occurring and to facilitate good practice amongst staff. The en-suite bathrooms are o not assisted and therefore often not used due to the frailty of the residents. The home has two communal baths this is below the acceptable standard of bathing facilities. The management must assess this situation and produce a plan on how this can be appropriately dealt with. The home must ensure that vegetables and perishable foods are fresh and kept in a cold place. The kitchen windows must have fly screens to prevent contamination of foods. The registered provider must ensure that induction training is followed through and foundation training is also implemented to ensure that the work force is suitably trained for their individual roles. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 7 There are a number of areas of concern that the home has not addressed since the last inspection, this impacts on the management of the staff and care given, improvements in these areas is required with urgency. Such as supervision and training of staff. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 8 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 Standards Statutory Requirements Identified During the Inspection Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 9 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 standard(s) 1, 2, 3, 4 The home has not produced a Statement of Purpose or Home Guide therefore residents cannot use their right to choose prior to admission. The home does not produce detailed care plans based on the assessment prior to admission consequently residents care needs may not be fully met. EVIDENCE: The Statement of Purpose which contains information concerning the home and the Home’s Guide which gives information to prospective resident is only available in the draft and is not available to the general public. Three residents spoken to said that they had not chosen to live in the home and think that this decision was made by their families. The residents or their representative had signed the Terms and Conditions of Residency, these are the originals; neither the resident’s nor their representatives are given copies. The acting manager assesses the needs of all residents prior to admission; the forms are basic and cover the main areas associate with health, well-being, Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 10 strengths and weaknesses. Care plans are developed from this initial assessment; the plans of care need to contain more information to ensure that all needs are met properly. It was assessed that a resident was disorientated in time and place no care plans were available, in another instance a resident with a urinary catheter had no care plan or guidance on catheter care. (For more information see Health and Personal Care). The home inform residents and their representatives that they are able to meet their needs prior to admission, the care plans and staff understanding of the needs of the residents is below standard. The staff have insufficient training in caring for residents with memory problems, dementia and distress. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 11 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 standard(s) 7, 8, 9, 10, The residents’ health, personal and social care are not clearly set out in the individual plans consequently not all needs are met. The residents are protected by the home’s policies, procedures and practices in dealing with medicines. The staff ensure that the privacy and dignity of the residents is respected consequently the residents maintain individuality. EVIDENCE: Written records related to the care of resident’s are very basic and does not cover all the areas of care required. One resident’s assessment indicated a risk of pressure sore development; the home had failed to write a plan of care to reduce this risk. The plans of care are not signed by the residents or their representatives, which would indicate that they are unaware of the care being provided by the home. The plans of care are not reviewed monthly therefore changes in care needs are not followed through. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 12 Regular nutritional assessments are not carried out on any residents. The records of one resident showed weight loss had occurred. There was no plan of care to address this for example no other professionals have been involved. The resident has been placed at risk of malnutrition and other ill effects of weight loss. Administration of medication was very good, and the records are completed appropriately. Only suitably trained staff give out medication. The privacy and dignity of the residents is respected. It was seen that staff knock on bedroom doors before entering, and ensure that all residents are dressed in their own clothes. Staff were heard to address residents in a respectful and appropriate manner. The residents have the use of a public phone, cordless line belonging to the home and may at their own expense have a personal phone. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 13 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 standard(s) 12, 13, 14, 15 The residents’ lifestyle experience in the home matches their recreational, social, cultural and religious interests and needs. The also home ensure that residents’ maintain contact with their family and friends and have choice and control over their life. Consequently they have a good quality of life. There home supplies three main meals each day and residents are given a choice at each mealtime resulting in residents exercising their right to choose and ensuring their well-being. EVIDENCE: A record of the likes and dislikes of the residents is available in the profile of each resident, which also includes a description of the individual’s daily routine. Activities are ad-hoc and staff stated that this was dependent on the wishes of the residents, the staff on duty and the weather. The record of activities showed that on some days there were fewer activities than on others. A record of the individual resident’s activities and participation is maintained in a diary, some days did not have an entry, it could not be confirmed if this is an indication that there were no activities on these days, or did the staff fail to record the event. During the morning some residents went out in the home’s bus. One resident was seen preparing vegetables for lunch and said that she enjoyed doing this Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 14 each day and she felt useful. In the afternoon some residents and staff were making flags to adorn the lounge for a party. Residents spoken to said that their families visit regularly and staff are always welcoming. The acting manager said that relatives and friends may visit at any time and can join the resident for a meal if they wish. The residents are allowed to bring to the home pictures, photographs, ornaments and smaller items of furniture; these were seen while touring the home. Information about local advocacy services and other organisations that offer advice and assistance was displayed in the main reception area. The home has a four-week menu that has a choice for each main meal. Breakfast is served from 07:00 hours until 10:00 hours this was seen during the inspection. Four residents said that the food was tasty and that they always had enough to eat. The atmosphere during the main meal was relaxed and residents were heard chatting and laughing. Assistance was given in a professional and quite manner. During the tour of the kitchen it was noted that the vegetables were not fresh and beginning to perish, and the area where they were kept was very warm. There are no fly screens at the windows and no other equipment to ensure that flies do not enter this area, which could result in contamination of food. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 15 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 standard(s) 16, 17, 18 All complaints received by the home are dealt with promptly and in accordance with local and national guidance, therefore protecting the residents’ rights. Residents’ are able to participate in the . Policies and procedures concerning the protection of vulnerable people are inadequate, putting residents at risk. EVIDENCE: The home has received one complaint on 16th April 2005, the records showed that this was followed up appropriately and copies of the complaint and letters sent were available. The acting manager stated that the procedure for making complaints is issued to all residents and their representatives this could not be confirmed. Residents spoken to said that they could always talk to the acting manager and other staff if there was a problem and two residents said that they would tell their family. Residents were not aware of the home’s policies and procedures for complaints. Postal voting was discussed; staff were unaware that the resident must complete this form without interference from others. One staff member stated that in the case of a resident being unable to make the decision the family would be asked and the ballot paper filled in on their instruction. This practice is a misuse of the postal voting and staff appeared unaware of this. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 16 The home has had no allegations or suspicions of abuse. The policies and procedures are not complete and require further information. The home has no Whistle Blowing policy and that all staff are unaware of the role of the Protection of Vulnerable Adults (POVA). It was seen in the staff employment records that all staff are checked for inclusion on the POVA list and criminal records as part of the employment process. Four staff spoken to were aware of the issues surrounding abuse and vulnerable adults, they were not aware of the role of POVA and Adult Protection strategies. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 17 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 standard(s) 19, 20, 21, 24, 25, 26 The environment is generally untidy, dirty and some repairs are needed to increase the comfort and safety of the residents. The gardens are well maintained and accessible, so the residents can take pleasure in these areas. EVIDENCE: The home is on a busy road in Rugby and has car-parking facilities to the front of the building. There are gardens to the sides and rear of the property, which have mature flowerbeds and trees and are on one level allowing access by all residents. Four residents spoken to said that they enjoyed the garden in the summer and one resident said that she liked the garden very much and could enjoy the view and the birds from her bedroom. The home has two main lounge areas. The smaller lounge leading to the conservatory was not in use during that day and was untidy and disorganised. The manager said that this area is used during the summer more than the Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 18 winter, she could not say why. It was seen that the residents spent the day in the main lounge, which contains the dining area. The furniture in the main lounge and dining room is comfortable and in good repair, there are a variety of single chairs and settees. Residents spoken to stated that they were happy with the lounge and felt comfortable and safe. The home has two communal baths with hoists to assist residents with bathing. During the tour it was confirmed that the en-suite baths and showers are rarely used, as residents often cannot access these facilities due to frailty. The residents’ bedrooms are appropriately furnished and personal items were seen. In one bedroom the carpet was poorly fitted and in areas this could cause a trip hazard, another bedroom required a new carpet as the present one is worn. The home has secondary double-glazing throughout, the areas between these were unclean and the main windows are in need of painting. The guttering around the home and the roof of the conservatory were seen to be full of dirt, dry leaves and stray foliage. The laundry is situated in the small boiler room, the boiler was being serviced at the time of the inspection and the gas engineer stated that the staff must stop blocking the vents as this prevents proper ventilation and emission of gases. This area does not have suitable flooring and the walls cannot be washed, which may cause cross infection. The laundry was untidy and disorganised with residents lost clothing and odd socks, as the laundry is small and there is limited space this could result in trips. Clothes worn by the residents and those seen in wardrobes were clean and ironed. Some clothing required buttons and minor repairs. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 The staffing of the home is adequate and the recruitment policies and procedures ensure the support and protection of the residents, training of staff in their roles is insufficient. EVIDENCE: Staff were seen in the main areas of the home throughout the day, and residents spoken to said that the staff were friendly and kind and responded to their needs. The care staff are responsible for the washing of the residents clothes and linen and for finishing the teatime meal and leaving the kitchen tidy. One staff member was seen after the main meal in the afternoon carrying out the laundry, other staff were in the main lounge with the residents organising activities. Three care staff have completed training to NVQ level II in care and two staff have completed training to NVQ level III. A further three staff have commenced NVQ training. Staff spoken to said that the training had helped them to carry out their work more effectively. Records seen indicated that the employment procedures are adhered to and all checks are made ensuring that suitable staff are employed, and that residents are safe from harm. The induction programme in place is not completed appropriately for all staff and there is no foundation training, indicating that staff are not formally Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 20 introduced to the working practices of the home, this could reduce the consistency of care and poor practices could develop. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 37, 38 There is inadequate leadership, guidance and direction to staff, so there is inconsistent care and safety of residents may be at risk. EVIDENCE: The manager has her NVQ level IV in Management of Care and has also attended training in the care of those with dementia, so should be able to ensure that the assessed needs of the residents is met. staff meetings are held six monthly and information is shared daily during the handover period. Records seen confirmed this and staff spoken to felt supported by the acting manager. The Regulation 26 unannounced monthly visits by the registered provider of the home are not being carried out as required, and there are no quality assurance or monitoring systems in place. The home cannot demonstrate that Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 22 it is monitoring the service and making changes to ensure growth and improvements. The staff are not receiving regular supervision and the records are incomplete. Supervision allows the staff to discuss training issues, care issues and to discuss common parts of the work. Staff spoken to were not aware that they should receive supervision six times a year. Records examined were disorganised and the acting manager had to spend time finding information requested. The records related to the residents and the running of the home are maintained in a secure place. Records seen confirmed that the management organises statutory training for the staff. It was seen in the records that some staff have not attended this training. Most of the health and safety checks of equipment in the home have been completed. Portable electrical equipment is not tested prior to use and on a yearly basis visual checks alone are insufficient. All hot water outlets and selected cold-water outlets are not checked monthly and there is no Legionellas Assessment. Both these issues may put the residents at risk. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 23 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 3 3 2 x x 2 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 2 2 3 1 x N/A 1 2 2 Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 24 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 OP1 Regulation 4, Schedule 3 Requirement The registered provider has devised a Statement of Purpose and a Service Users Guide, both documents require further work to include all the information required . (Tme scale of April 2002 not met. ) The acting manager must ensure that suitable plans of care are developed that reflect the assessed needs of the residents prior to admission. The acting manager must ensure that planned care reflects current guidelines and that clinical specialist advice is sought. The planned care must contain adequate detail to ensure that there is consistency of care provided. The registered provider must ensure that where possible the service user and/or their representative sign the plans of care to signify agreement to the plan. ( Time scale of 30.06.04 not met) The must ensure that the plans of care are evaluated monthly and where appropriate, after Timescale for action 30.05.05 2. OP3 15, Schedule 3(1)(b) 12(1) 31.06.05 3. OP4 30.05.05 4. OP7 15(1) 31.06.05 5. OP7 14 31.06.05 6. OP7 14(2)(a), 15(2)(c) 31.06.05 Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 25 7. OP8 17(1)(a) Schedule 3 8. OP8 13(1)(b) 9. OP15 16(2)(j) 10. OP18 13(6) 11. OP18 13(4), (6) 12. OP21 23(2)(j) consultation with the service user or their representative, revised care is planned. (Time scale of 30.06.04 not met.) The registered provider must ensure that nutritional screening is undertaken on admission and subsequently on a periodic basis, a record must be maintained of nutrtion including weight gain or loss, and appropriate action taken. All this information must be recorded. (Time scale of 31.12.04 not met) The registered provider must ensure that the pyschological health and well being is monitored regularly, and that any preventative or restorative care is being provided. ( Time scale of 30.06.04 is not met) The registered provider must ensure that there are fly screens at the kitchen windows as required by health and safety in kitchens. The registered provider must ensure that there are the following policies and procedures A) Whistle Blowing Policy - B) Inclusion on the the Protection of Vulnerable Adults list policy and procedure. The registered provider must ensure that there is a writen procedure in accordance with local policy on dealing with allegations and suspicions of abuse. The registered provider must ensure that there are adequate bathing facilities that can be used by the service users. A risk assessment must be carried out and an action plan of work required with projected time scales must be completed and sent to the Commission for 31.05.06 30.06.05 30.06.05 30.07.05 30.07.05 30.08.05 Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 26 Social Care Inspection. 13. OP21 23(5) The registered provider must ensure that all water outlets that are not in use are flushed for two minutes every seven days as part of Legionelleas risk reduction. The registered provider must ensure that worn carpets are replaced in the service users bedrooms and a full risk assessment is conducted and work carried out where there is a recognisable risks. The registered provider must ensure that the areas between the secondary double glazing the fixed windows is kept clean and the outer windows are painted where required. The registered provider must ensure that the Hot and Cold Water Outlets are checked monthly, where required restoration and repair is carried out. Records must be maintained and available for inspection. The registered provider must ensure that the walls and flooring in the laundry are washable and none permiable. The registered provider is required to submit an action plan to the Commission detailing how the home is to achieve a minimum ratio of 50 trained care staff (NVQ level II or equivalent). (Time scale of 10.11.04 not met) The registered provider must ensure that staff receive induction training to National Training Organisation Standards within six weeks of appointment. (Time scale of 10.11.04 not met) The registered provider must ensure that there is a suitable 31.05.05 14. OP24 16(2) 30.07.05 15. OP25 16(2)(j) 30.07.05 16. OP25 16(2)(j), 23(2)(p) 31.05.05 17. OP26 13(3), 16(2)(e)(f )(j) 18(1) 31.08.05 18. OP28 30.07.05 19. OP30 12(1)(a)( b) 13(4)(c) 31.06.05 20. OP30 12(1)(a)( b), 31.08.06 Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 27 21. OP30 22. OP31 23. OP33 24. OP33 25. OP36 26. OP38 27. OP38 28. OP38 18(1)(a)(c Foundation Programme for care ) staff to commence once they have completed the Induction Training. 18(1)(a)(c The registered provider must ) ensure that all persons working at the home receive training appropriate to the work they perform. (Time scale of 10.11.04 not met) 9(1)-(3) The registered provider must ensure that the acting manager applies to the Commission for registration. 26 The registered provider must ensure that monthly unannounced visits to the home are carried out and a report is produced and available for inspection. 24(1)(a)( The registered provider must b),(2)(3) ensure that there is a suitable quality assurance and quality monitoring systems in place and records are maintained and avialable for inspection. 18(2) The registered provider must ensure that all care staff revieve formal supervision six times a year and records are maintained and available for insection.(Time scale of 15.11.04 not met) 23(5) The registered provider must ensure that the temperature of the hot and cold water outlets are checked monthly and records are maintained, idicating remedial action where necessary. 13(4) The registered provisder must ensure that all portable electrical equipment is checked prior to use and on a yearly basis, visula checks are not sufficient. 23(5) The registered provider must ensure that a full Legionelleas assessment is conducted and a action plan produced to reduce E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc 31.08.07 30.05.05 30.05.05 31.06.05 30.05.05 30.05.05 30. 06.05 31.07.05 Red House Residential Home Version 1.20 Page 28 assessed risks. 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 OP2 OP10 OP38 Good Practice Recommendations It is recommended that a copy of the Terms and Conditions of residency is given to the service user and/or their representative for future reference. Staff induction programmes should identify the arrangements for maintaining the privacy and dignity of the residents, and should clarify what the staff role is. It is recommended that the files required by regulation for the protection of service users and the effective running of the home are better organised. Red House Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 29 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Residential Home E53 s4285 Red House Residential Home v218508 110405 Stage 4.doc Version 1.20 Page 30 - 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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