Inspection on 22/07/08 for Red House, The

This inspection was carried out on 22nd July 2008.

CSCI found this care home to be providing an Good service.

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 23/08/07

Red House, The 11/05/06

Red House, The 27/10/05

Red House, The 19/06/05

Red House, The 06/09/04

Red House, The 26/04/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Red House, The 423 West Green Road Tottenham London N15 3PJ Lead Inspector Mr David Hastings Unannounced Inspection 10:00 22 and 23rd July 2008 nd 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 DS0000033328.V368257.R01.S.doc Version 5.2 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 DS0000033328.V368257.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Red House, The Address 423 West Green Road Tottenham London N15 3PJ 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) 020 8889 0097 020 8888 0311 joyohiri@haringey.gov.uk London Borough of Haringey Joy Ohiri Care Home 35 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (18) of places Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. These persons who are in the category DE (E) must be accommodated in the living unit identified for this purpose. 23rd August 2007 Date of last inspection Brief Description of the Service: The Red House is a purpose built home located in the West Green area of Tottenham. The home is close to local shopping and transport facilities, and a short distance from the shopping and entertainment facilities of Wood Green. The home is provided and managed by the London Borough of Haringey Social Services Department with the aim being to provide care with dignity for up to 35 people who are elderly. The home is arranged over two floors, with two units on each floor. Each unit has its own lounge and kitchenette, and there is also a large communal lounge located on the ground floor. Some residents have additional physical disabilities and dementia needs associated with ageing. In addition to providing care for residents, the home employs of a full time activity co-ordinator. Inspection reports produced by the Commission of Social Care Inspection (CSCI) are available upon request from the registered manager/provider. Placements at the home cost around £530 for each person per week. Residents are expected to pay separately for some items and activities, such as hairdressing or eating out. Following Inspecting for Better Lives the provider must make information available about the service, including inspection reports, to service users and other stakeholders. Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This Key Unannounced inspection took place on Tuesday 22nd July 2008 and was completed on the Wednesday 23rd July 2008. The inspection lasted nine hours. We spoke with eight staff on duty during the inspection. We spoke with ten residents of the home and three visitors. We observed the interactions between staff and residents. We inspected the building and examined various care records as well as a number of policies and procedures. What the service does well: What has improved since the last inspection? Seven requirements were issued at the last inspection. One of these requirements related to a resident who is no longer at the home. This requirement has been withdrawn. The registered person has complied with the other six requirements. Residents of the home now have a written contract so everyone should now be clear about the terms and conditions of the service. Staff have now received adult protection training and are more aware of the issues vulnerable people face living in a residential home. One staff told us, “Adult abuse is something that people don’t always notice”. Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 6 The building has been extensively refurbished and as a result is now more secure for those confused residents who are at risk from leaving the home unaccompanied. The leak in the roof on the ground floor has also been repaired. Self closing door guards have been fitted to all bedroom doors that individual residents wish to remain open during the night. This means that people can choose if they want their door open without this being a fire hazard. Staff have undertaken training in back care, fire safety and falls prevention. Staff we spoke with told us this has improved their work practices as well as improving residents’ safety. Seven good practice recommendations were also issued at the last inspection. The registered person has carried out three of these. Staff are assessed before they administer medication to people who use the service. This should ensure that staff are more confident and residents are better protected. The manager has developed a staff training overview so that it is clear who has received the training they need and what further training needs to be provided. 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. The summary of this inspection report can be made available in other formats on request. Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 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 DS0000033328.V368257.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 (6 not applicable) People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. Residents are also given clear information about the terms and conditions of the service. EVIDENCE: We examined three assessments of people who have recently moved into the home. The manager told us that someone from the home would visit a prospective resident and carry out an assessment of their needs before they moved in. These assessments were detailed and covered all the elements required by this Standard including the assessment of physical, emotional, social and cultural needs. We also found that the information from these assessments was being recorded on peoples’ care plans as well. People who use the service and their relatives told us that they were involved in this Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 9 assessment process and, where possible, had visited the home before moving in on a trial basis. The manager was able to describe how the needs of people from different backgrounds and cultures can be met at the home including appropriate diets and religious observance. A good practice recommendation was issued at the last inspection that the organisation look at ways of targeting staff recruitment to Greek and Cantonese speakers. The manager said that this is an ongoing issue and that the home would continue to try and employ people who speak languages that are spoken by residents of the home. Six care plans were examined. Each plan included a written contract of the terms and conditions of the home. These plans had all been signed by the resident or their representative. This was a requirement from the last inspection and should ensure that both the home and the resident are clear about the terms and conditions of the service. Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans clearly set out residents’ health, personal and social care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Five care plans were examined. Each plan had a summary of the person’s care needs including their physical, emotional and social needs. Each plan gave clear instructions to staff about how best to care for each person. Care plans were being reviewed on a regular basis and updated where needed. Each person’s plan of care included an assessment of the risk of falling and how staff are to reduce this risk, for example, having two staff to help with personal care tasks or by supervising the resident when they walk around the home. Two good practice recommendations were issued at the last inspection regarding the way falls at the home are monitored. Some work has been done by the manager to analyse the incidents of falls to see if any patterns emerge that Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 11 could help staff to reduce the number of falls at the home. This was discussed with the manager who agreed to add further indicators, including the time the fall happened. As further work in this area needs to be done, both recommendations have been included again in this report. Other risk assessments were seen including moving and handling, pressure care and nutrition. People who have been assessed as being at risk from developing pressure sores had special mattresses to reduce this risk. Visits by health care professionals such as doctors, district nurses, chiropodists, dentists and opticians were being recorded on plans we examined. These showed that people had good access to these professionals. This was also confirmed by residents and relatives we spoke with. The doctor visits twice a week and staff record any problems in the “Doctors’ book”. The staff record the outcome of the doctors’ visits in this book. Care plans were being reviewed but there was little evidence that residents had been involved in the review of their plans. Although all the people we spoke with said they were happy with their care, it is important that people are given an opportunity to decide if they want changes to their plan of care. A requirement has been issued that people are consulted about their care and the quality of the care they receive on a regular basis when their care plan is being reviewed. Satisfactory records were examined in relation to the receipt, storage, administration and disposal of medication. Records indicated that staff have undertaken medication training and only qualified staff administer medication at the home. The manager told us that after staff have undertaken the training, they are observed and their competence is assessed before they administer medication to residents. This was a good practice recommendation given at the last inspection. This should ensure that residents are confident that staff can administer medication to them safely. Each person’s medication chart has a picture of them attached to it so that staff can double check who is receiving the right medication. We saw a number of examples of supportive staff interactions with people and staff were able to describe to us how they ensure the privacy of people they support. We saw staff knocking on resident’s bedroom doors before entering. People we spoke with told us that the staff were respectful and kind towards them. One resident told us, “The staff are respectful”. Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides varied activities for people who use the service in order to keep them suitably occupied and engaged. The home encourages visitors, which ensures an interesting and lively atmosphere. Residents are able to exercise choice and control over their lives. The home provides people with a wholesome appealing balanced diet. EVIDENCE: People’s interests and social and cultural needs are recorded on their plan of care. There are some residents from different backgrounds and cultures living at the home. The manager said that the cultural needs of these residents’ are being met by the home and appropriate food can be provided by the kitchen if needed. We saw evidence that culturally appropriate food is being provided at the home. The home employs an activity coordinator but they were not working on the days of the inspection. However, there appeared to be enough staff on duty to make sure that residents were suitably engaged and occupied. Staff were observed sitting and chatting with residents and residents were clearly benefiting from the staff contact. The garden has been recently replanted and contained garden Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 13 furniture including a large umbrella. Residents and their relatives were seen enjoying the outside space on the days of the inspection. People we spoke with said they were happy with the activities put on by the home. One person was particularly impressed with the new “Cinema room” which has a large wide screen television. The home also arranges trips out of the home as well as a recent fete. We saw a number of visitors to the home during the inspection. Visitors told us that they could visit at any reasonable time and that they were made welcome by the management and staff. Residents we spoke with confirmed this. One visitor told us, “They always say Hi” and “They always ask if I want a cup of tea or coffee”. The home has regular residents’ meetings and minutes examined indicated that residents have a say in how the home is run. The minutes also provided evidence that residents are consulted about the menus in the home. Staff we interviewed were able to give us practical examples of how they offer choice to people living at the home. This included times that residents wanted to get up in the morning and making sure that residents were able to choose the clothes they wanted to wear. The kitchen was inspected. Fridge and freezer temperatures were being recorded and there were sufficient amounts of fresh fruit and vegetables available. The chef was interviewed and had a good knowledge of individual resident’s dietary needs and preferences. The menus seen contained a choice of meal as well as a vegetarian option. People told us that if they did not want what was on the menu the chef would always cook them something else. Residents also confirmed that the chef went around and asked them if they liked the meals provided. Cakes are prepared for all residents’ birthdays and the meals we saw on the day of the inspection looked and smelt appetising. People who use the service confirmed that the food was good at the home and that they always get enough to eat. One resident told us, “I’ve got no complaints about the food”. Another resident said, “There’s quality and quantity”. Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and responded to in a professional manner. People at the home are protected from abuse by clear policies and procedures and by an appropriately trained staff team. EVIDENCE: The home has satisfactory policies and procedures in relation to complaints and the protection of residents from abuse. The record of complaints was inspected. There have been five complaints since the last inspection. Most of these complaints were minor and records seen indicated that they had been dealt with according to the home’s complaints procedure. There was a written record of the outcomes of these complaints so that it was clear what action the manager had taken. One complaint involved a member of staff who as a result of the complaint had been suspended pending an investigation. This matter was discussed with the manager and service manager of the home on the second day of the inspection. The service manager told us that this was discussed with the local authorities adult protection unit and all steps had been taken to protect residents at the home. The service manager agreed that, in hindsight, this matter should be dealt with using the local authorities adult protection procedures. This has now taken place. In order to assist the manager in deciding if an issue is a complaint or an adult protection matter, a requirement has been issued that further guidance is developed in relation to this. Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 15 Staff were able to describe how vulnerable people could be at risk of abuse in a residential care setting. All staff interviewed were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Residents that we spoke to said they felt safe and well supported at the home. One resident told us, “They are very kind”. The home has developed a training overview for all staff. This indicated that the vast majority of staff have completed training in adult protection. This was confirmed by staff we interviewed. The few remaining staff who have not attended this training are new to the home and we were told that further training will be booked. A requirement made at the last inspection, relating to adult protection training has now been complied with. Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is safe, clean and maintained and decorated to a good standard. EVIDENCE: We toured the home with the manager and visited a number of resident’s rooms. We also looked at the bathroom and toilet facilities in the home. The home has been extensively refurbished and redecorated. The general environment of the home has improved considerably and people who use the service now live in a much more pleasant environment. All external doors have been fitted with keypad locks that can only be opened by someone who knows the number. This means that very confused residents are not being put at risk from leaving the building unaccompanied. The manager told us that residents who are able to can come and go as they please. In the event of a fire all locks will open automatically. There is a maintenance book to record any problems so the maintenance person knows what needs fixing around the home. Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 17 We saw the laundry area, which has satisfactory equipment including facilities for sluicing bedding and clothes as required. All toilets and bathrooms contained anti-bacterial soap and disposable paper towels to limit the risk of cross infection. Mandatory training in infection control is also provided for staff. People we spoke with said the home was clean and there were no offensive odours present on the days of the inspection. Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff at the home work very hard to meet the needs of the residents and are provided with good training opportunities to further enhance their knowledge and skills. Recruitment practices are sufficiently detailed in order to protect residents at the home. EVIDENCE: People who use the service told us they were happy with the staff at the home and we saw good interactions between staff and residents. On the day of the inspection there appeared to be enough staff to meet the needs of the residents. Staffing rotas seen matched the names of the staff on duty that day. One person told us, “99 are absolutely fantastic”. Records provided by the home prior to the inspection indicated that twentyone members of staff out of thirty-three have completed their NVQ level 2 or equivalent. This exceeds the requirement of this Standard. As a result of a good practice recommendation issued at the last inspection the manager has developed a training overview for all staff. This gives a clear indication of the training undertaken by all staff at the home as well as highlighting any further training needed. Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 19 Staff were very positive about the training offered to them and staff training profiles examined indicated that staff at the home receive the training required to do their jobs effectively. Where staff needed refresher courses in mandatory training we saw that these courses had been booked for later in the year. A requirement was issued at the last inspection that staff receive training in falls prevention, fire safety and back care. These courses have now taken place and the majority of staff have completed them. More training has been booked for new staff. Staff members we interviewed said the courses were very useful and were able to give us examples of how the training has improved their work practices and therefore improved the safety of residents at the home. One staff member said, “The (falls prevention) course was a real eye opener for me” another staff member said, “It really helps me”. Staff told us that they now make sure that residents are wearing properly fitting shoes as this prevents falls. A good practice recommendation was issued at the last inspection that training in working with people with sensory impairments is provided for staff. The manager told us that this training has been booked for September this year. Four staff files were examined. Recruitment is carried out by the home in conjunction with the Human Resources unit in Haringey Council. We saw evidence that all staff are interviewed by the manager of the home and that the manager sees each candidate’s references, proof of identity and CRB disclosure before an offer of employment is made. This means that all staff working at the home have had the required checks carried out before they start working with residents. Some references did not include a company staff or letter headed paper from the referee. This would further confirm the authenticity of the references and a requirement has been issued relating to this matter. Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, and 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is working hard to improve the quality of care provided at the home. Residents have opportunities to have a say in how the home is run. Residents’ financial interests are being safeguarded. The health and safety of residents and staff are being promoted and protected. EVIDENCE: Staff and residents that we spoke with were positive about the registered manager of the home. One resident told us the manager was, “Very easy to talk to”. One staff member told us the manager, “Always asks us if we are OK” and “She checks everywhere”. The registered manager, Joy Ohiri has undertaken the training required to manage a residential home. There was also evidence that the manager attends Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 21 regular training. Recently the manager has attended training in risk assessments. The home undertakes regular quality assurance surveys for residents and their representatives. The results of these surveys are then published and made available to all interested parties. An action plan is then developed to address the issues raised as a result of the feedback. To further enhance the quality monitoring at the home a good practice recommendation has been issued that the management explore the use of “Dementia Care Mapping”. This is an observational tool that can monitor for signs of wellbeing in those residents with cognitive impairment. This should ensure that the staff at the home can assess whether they are providing a good level of care and support for those people who have dementia and may not be able to express their opinions verbally. There was also evidence from residents’ meetings that people can have a say in how the home is run. For example the manager told us that the menus have changed as a direct result of residents’ comments. Each resident has their own personal account for their money with the local authority. The administrative staff were able to explain how this system works and accounts that we examined were accurate and clear audit trails were evident to ensure that residents are protected from financial mismanagement. The manager told us that residents or their representatives receive a statement of the their account every two months. The service manager for the home told us that the system was being reviewed to ensure that all residents would be able to obtain interest on these accounts. A requirement was issued at the last inspection that risk assessments are carried out for any person that wishes their bedroom door to be open particularly during the night as this may present a fire risk. The manager told us that as a result of these risk assessments self closing door guards have been fitted to those doors that residents wish to remain open. We saw door guards on a number of doors throughout the home. This means that residents now have a choice to keep their door open in a safer way. We did not see any doors being wedged open during the inspection. We examined satisfactory records in relation to other health and safety issues including electrical safety, gas safety, Legionella control and fire safety. Although fire drills are taking place on a regular basis, a requirement has been issued that night staff undertake fire drills every three months. This should ensure that night staff are aware of the procedures and action to take to protect residents if a fire occurs at night. The manager told us that there is always a senior manager sleeping in the home during the night. Staff training records indicated that staff are undertaking the required health and safety training in order to protect both residents and staff. Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 22 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 X 3 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 4 14 3 15 3 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 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 23 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 15(2) c Requirement The registered person must ensure that residents or their representatives are consulted about their care and are given the opportunity to comment on the quality of the care each time their care plans are reviewed. This is to ensure that people have a say in how they would like their care to be delivered. The registered person should ensure that there is clear guidance for the manager in clarifying if a complaint or other concern received may need to be investigated using the homes adult protection procedures. The registered person must ensure that all professional references include a company stamp or letter headed paper to further confirm its authenticity. The registered person must ensure, by means of fire drills and practices at suitable interviews, that the persons working at the care home and, so far as practical, service users, are aware of the procedure to be DS0000033328.V368257.R01.S.doc Timescale for action 01/10/08 2. OP18 13(6) 01/10/08 3. OP29 19(1) c 01/10/08 4. OP38 23(4) e 01/10/08 Red House, The Version 5.2 Page 24 followed in case of fire, including the procedure for saving life. This includes night staff who should undertake fire drills every three months. This should ensure that night staff are aware of the procedures and action to take to protect residents if a fire occurs at night. 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. Refer to Standard OP8 Good Practice Recommendations It is recommended that the registered persons review the system of recording and monitoring the falls that residents have in the home, and that the monitoring information regarding the numbers of falls that residents are having is discussed regularly, as a standing item on the staff meeting agenda. It is recommended that staff be reminded to record the time of any fall that residents have to aid in monitoring and prevention. It is recommended that the registered person consider methods of targeting staff recruitment to Greek and Cantonese speakers. It is recommended that staff be provided with training in working with people with sensory impairments. The registered person should explore ways that “Dementia Mapping” could be used as part of the home’s quality monitoring systems 2. 3. 4. 5. OP8 OP12 OP12 OP33 Red House, The DS0000033328.V368257.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000033328.V368257.R01.S.doc Version 5.2 Page 26 - 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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