Inspection on 01/11/05 for Red House (The)

This inspection was carried out on 1st 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Red House (The) 29/11/07

Red House (The) 14/11/06

Red House (The) 31/05/05

Red House (The) 11/01/05

Red House (The) 05/08/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Red House (The) 43 Skinners Lane Ashtead Surrey KT21 2NN Lead Inspector Sarah Radlett Unannounced Inspection 1st November 2005 09:15 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 Red House (The) DS0000013362.V262802.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. Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Red House (The) Address 43 Skinners Lane Ashtead Surrey KT21 2NN 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) 01372 274552 01372 277880 The Red House (Ashtead) Limited Mrs Margaret Mary Josephine Chu Care Home 25 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (23) of places Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. For seven days of the week there must be 2 registered nurses on duty for the morning shift Of the 2 service users receiving personal care, only 1 may fall within the category DE(E) Of the 25 service users, up to 23 may be service users requiring nursing care Of the 23 service users receiving Nursing Care, 1 may fall within the category DE(E) The age range of residents within categories OP or DE(E) is 60 YEARS AND OVER 31st May 2005 Date of last inspection Brief Description of the Service: The Red House is a large, detached house, situated in a quiet residential area, close to the village of Ashtead. The home provides nursing care for up to twenty five people, of which up to two may have a diagnosis of dementia. Accomodation is on two floors with access to the first floor by a passenger lift. There are two dining ares, and a lounge with a spacious conservatory area. There are very attractive and well maintained gardens, which are easily accessible to the service users. Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5½ hours and was the second inspection carried out by the Commission for Social Care Inspection for the year 2005-2006. Sarah Radlett carried out the inspection. The Registered Manager and Deputy were present throughout the inspection. A tour of the premises took place and various written records were examined, including five care plans and service user assessments, the complaints record, a sample of the required safety certificates, staff recruitment files and a sample of the medication administration records. The inspector spoke to Service Users, and some of the staff on duty at the time of the inspection. The Inspector would like to thank the staff and Service Users for their time, assistance, and hospitality during the inspection. What the service does well: What has improved since the last inspection? The recording of the administration of medication had improved since the previous inspection. The Registered Manager and Deputy are committed to training, including NVQ training, shortfalls in staff training noted at the previous inspection had been addressed and the home had a comprehensive training programme, all staff have had abuse awareness training. Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 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 (The) DS0000013362.V262802.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 Red House (The) DS0000013362.V262802.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 & 6 The information enabling Service Users to make an informed choice about where they live was available to all existing and prospective Service Users. EVIDENCE: The homes Statement of Purpose and Service Users Guide were seen. They contained all the required information and were presented in a clear manner. The care plans inspected had a pre-admission needs assessment completed. The assessment covered all elements of physical, mental, and social needs. The home does not provide Intermediate Care. Red House (The) DS0000013362.V262802.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): 7, 8, 9 & 10 Comprehensive care plans are in place, they clearly set out the Service Users health, personal and social needs; however one of the care plans examined was not accurate and fully completed. The recording and administration of medication were in line with the homes medication policy. Care was provided in a respectful manner. EVIDENCE: Samples of care plans and daily statements were looked at. The care plans were detailed, comprehensive and signed by Service Users wherever possible to evidence their involvement in their care. However one of the care plans examined was not accurate and fully completed. There was regular review of whether the Service Users needs had changed. Appropriate risk assessments were completed. Risk assessments were in place for the use of ‘bed-rails’, however there was no evidence of consent from Service Users regarding their use. Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 10 Service Users were registered with local GPs and had access to other health care services including chiropodist and dentist. The homes recording and administration of medication were in line with the homes medication policy; the recording of the administration of medication had improved since the previous inspection. One Service User had chosen to selfadminister their medication. Examination of records evidenced that an appropriate risk assessment was in place. Service Users spoken with were very complimentary regarding the home, they commented that they were treated with dignity and respect by the staff. Comments included, ‘we are not put under any pressure to do anything. We are allowed to make are own choices’, and ‘the staff are very kind and caring’. Staff were observed to treat the Service Users in a friendly, but professional way. Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 11 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): 12 & 14 The activities provided by the home were varied, and stimulating. Service Users were encouraged to maintain their interests. EVIDENCE: There was an activities organiser in place. A programme of activities was displayed offering a range of pursuits. Service Users were able to go out to church and there was also a monthly service held within the home. Service Users spoken to were happy with the activities provision within the home, and were particularly pleased that they were actively encouraged to make their own choices and felt in control of their lives. Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 12 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): 16 & 18 The home had a simple and accessible complaints procedure. Staff receive training in the protection of vulnerable adults. EVIDENCE: The home had a simple and accessible complaints procedure. There had been 11 complaints detailed since the last inspection. It was pleasing to note that the manager followed the complaints procedure even for minor concerns, and all complaints were managed efficiently with a satisfactory outcome. Several Service Users spoken to during the inspection were aware of the complaints procedure, and felt confident about using the process. The home had a policy on abuse and a whistle blowing policy; these documents did not contain clear guidelines regarding reporting of incidents. A copy of Surreys Multi-Agency Procedure for Vulnerable Adults policy was available. Staff receive training in the protection of vulnerable adults. Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 13 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 & 26 The home was suitable in layout for its purpose. The home was found to be clean and tidy. EVIDENCE: The inspector toured areas of the home. It was seen to be clean, tidy and free from offensive odours. The premises were seen to be well maintained with service users able to access all areas of the home and grounds. The gardens were well maintained. Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 14 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 staffing arrangements in place on the day of the inspection were sufficient to meet the needs of the Service Users. The Registered Manager ensures that staff receive appropriate training, including NVQ training. The recruitment process was being followed to ensure that only suitable staff were being employed. EVIDENCE: The staff rota inspected demonstrated that the staffing numbers and skill mix were appropriate to meet the assessed needs of the Service Users living in the home. The Registered Manager and Deputy are committed to training, including NVQ training, shortfalls in staff training noted at the previous inspection had been addressed and the home had a comprehensive training programme. All new staff members receive induction training and there was evidence of ongoing training for staff, including Service User specific training. The Staff file of a new member of staff was examined at inspection. The file contained the necessary checks and references and evidence of induction Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 15 training covering aspects such as moving and handling, fire training, and elements of care. Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 16 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, 33, 35, & 38 The home has systems in place to monitor the quality of care and services provided. There was no evidence of the systems in place to safeguard the financial interests of Service Users. Policies and procedures were in place to ensure, as far as is reasonably practical, to ensure the health, safety and welfare of Service Users; however at the time of the inspection a fire exit was found to be obstructed. EVIDENCE: The Registered Manager is qualified, competent and experienced to run the home, she has an NVQ level 4 in care and management. All Service Users spoken to spoke very highly of the homes manager. Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 17 The home completes an annual survey of all service users. The results are correlated in to a report, and displayed on the notice board. Regular meetings take place between the activities organiser and the Service Users any issues raised are then feedback to the Registered Manager and the Deputy and dealt with appropriately. Procedures are in place to safeguard the financial interests of Service Users. A member of staff is the appointee for a Service User. The Registered Manager stated that written records of financial transactions are maintained; however these records were not on the premises and thus not available for inspection. Samples of health and safety certificates were inspected and found to be in order. During a tour of the premises a fire exit was seen to be blocked, an immediate requirement was made and this was dealt with at the time of the inspection. Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 18 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 1 X X 2 Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 14 15 Requirement 14 (2)(b) & 15 (2)(b)(i) - The registered person must ensure that the individual care plans for all service users are kept up to date and fully completed. 12 (2)(3), 13 (6)(7) & 17 (1)(a) Schedule 3 (3)(q) - The Registered Person must ensure that there is evidence that Service Users consent to the use of ‘bed-rails’. 13 (6) - The Registered Person must ensure that policy on abuse and the whistle blowing policy contain clear guidelines regarding the reporting of incidents. 16 (2)(l), 17 (2) Schedule 4 (3)(8) & 20 (1) - The Registered Person must ensure that written records of financial transactions are maintained, on the premises and available for inspection 13 (4)(a)(c) & 23 (4)(b) - The Registered Person must ensure that all fire exits are free from hazards. Timescale for action 01/12/05 2 OP7 12 13 17 Schedule 3 13 01/12/05 3 OP18 01/02/06 4 OP35 16 17 Schedule 4 20 13 23 01/12/05 5 OP38 01/11/05 Red House (The) DS0000013362.V262802.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. Refer to Standard Good Practice Recommendations Red House (The) DS0000013362.V262802.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 (The) DS0000013362.V262802.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!