Inspection on 29/11/07 for Red House (The)

This inspection was carried out on 29th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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) 14/11/06

Red House (The) 01/11/05

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 Sue McGrath Unannounced Inspection 29th November 2007 10:00 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.V347091.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) DS0000013362.V347091.R01.S.doc Version 5.2 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 www.redhouseastead.co.uk 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.V347091.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 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 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) 14th November 2006 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. Accommodation is on two floors with access to the first floor by a passenger lift. There are two dining areas, and a lounge with a spacious conservatory area. There are very attractive and well maintained gardens, which are easily accessible to the service users. The current fees are £ 925.00 per week. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place on the 29th November 2007 and was conducted by Mrs Sue McGrath, Regulation Inspector for the Commission for Social Care Inspection. The key inspections for care home services are part of the methodology for The Commission For Social Care Inspection, whereby the home provides information through a questionnaire process and further feedback is gained through surveys sent to service users and relatives and information provided from professionals associated with the home, wherever possible. The actual date of the site visit is unannounced. Additional information was also obtained through the Annual Assessment Quality Assurance (AQAA) review, which all services registered with the Commission for Social Care Inspection (CSCI) must now complete on a yearly basis. The home is to be congratulated for the comprehensive information provided in the AQQA. At the site visit, service users and staff were spoken to, records were viewed and a tour of the environment was undertaken. Judgements have been made based on records viewed, observations and verbal responses given by those people who were spoken with. These judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the CSCI to be able to make an informed decision about outcome areas. Further information can be found on the CSCI website with regards to information on KLORA’s and AQAA’s. The requirements made at the last inspection had been complied with. Overall this was a positive inspection with excellent outcomes for service users. The Commission would like to thank the staff, service users and visitors for their hospitality and co-operation throughout the inspection process. What the service does well: The home has an experienced registered manager who provides the home with management stability, leadership and direction to the staff team. Staff training is given a high priority, which ensures residents are in safe hands as far as possible. Activities at the home are well organised and the home employs a dedicated activities co-ordinator. Residents are fully involved in choosing what activities take place. Resident feedback both during the inspection and from written Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 6 comment cards indicates a very high degree of satisfaction with the activities offered and the general care at The Red House. Health needs are well met and care plans are comprehensive and regularly reviewed. The home values equality and diversity and encourages residents to participate in community life. Observations confirmed the home has arrangements for meeting the religious needs of residents and the home has organised regular services for those who wish to participate. Staff morale is high and staff are committed to providing a quality service. The home regular monitors residents’ wishes and takes action where possible. Residents stated they felt they were listened to at all times and were very complimentary about the staff group. Residents also confirm the food was very good and that drinks and snacks were freely available. They also confirmed that their relatives were welcome to join them for a meal at any time. What has improved since the last inspection? The home has met the requirements identified in the previous CSCI (commission for social care) inspection report. The home is currently updating its fire system with new fire doors already fitted, all with new intumescent strips. A new fire risk assessment is currently being written to ensure full compliance with the Fire Regulations. A new fire exit is also planned. Two fire evacuation chairs have been purchased. The home has two new industrial washing machines and a tumble dryer. The home has also invested in two overhead hoists and purchased twenty wheelchairs, all with maintenance contracts in place. The kitchen has benefited from a new fridge, freezer and industrial food mixer. A steam cleaner for the kitchen has also been purchased, along with new crockery and glasses. A ramp has been fitted to the main entrance to assists residents with mobility problems and a CCTV surveillance system has improved external security. The dining room has been repainted and some new furniture purchased. A cool water system is in place for the residents to use. A water softener has also been fitted. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 7 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) DS0000013362.V347091.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families are provided with the information they need to make an informed choice about moving into the home. Residents’ benefit from a comprehensive assessment of their needs prior to moving into the home to ensure their assessed needs can be met. Residents and families also benefit from the opportunity to visit the home prior to admission to assess the quality, facilities and suitability of the service. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 10 EVIDENCE: The home has a written Statement of Purpose and a Service User Guide, which is available to all residents. The home is recommended to review the document to ensure all elements of Schedule One of the Care Homes Regulations 2001 are fully included. Discussion with the manager confirmed that all residents undergo a thorough assessment of need prior to admission. These completed assessments were seen on the resident’s files. This assessment has recently been revised to include the homes responsibilities under the Mental Capacity Act 2005. The initial assessment form, which is used to assess service users’ needs, covers areas of personal care, social support and healthcare needs. The manager assured the inspector that they would not admit any resident until they are sure they can meet their needs. This includes assessing for any specialist equipment that may be required; no admissions are undertaken until the equipment is in place. All residents are supplied with a contract that confirms the terms and conditions with the home. Further evidence indicated staff working at the home had training in psychiatric nursing, dementia awareness, NVQ (National Vocational Qualification) in care, promotion of continence and collectively have the skills and experience to meet the needs of residents. Prior to admission the resident and or their family or representative are encouraged to visit the home to view what is offered. The prospective resident can stay for a meal or the day. After admission the home offers a four-week settling in period when either party can confirm needs are being met and the resident is happy to remain. This timescale could be extended if necessary. The home also offers respite care for short periods. The residents receiving intermediate care are clearly assessed for the sole purpose of rehabilitation and their planned return to their own homes. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from having clear and in-depth care plans that identify their individual needs and give clear guidance to staff Health needs are met and residents benefit from having full access to all professional health care services as required. The management of medications at the home promotes good health. EVIDENCE: The manager stated residents have individual care plans, which are drawn up following an assessment of needs. Several of these were viewed and found to contain comprehensive information regarding the personal care needs of the individual. Clear instruction to staff enables them to provide appropriate level of care. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 12 Where possible residents are encouraged to remain as independent as possible. Where assistance is required it was seen to be offered in a kind and caring way. Some excellent examples of care were observed during the day and clearly the relationships between staff and residents was relaxed and comfortable. All of the residents spoken with were very complimentary of the management and staff team. Some of the comments made were as follows: ‘The staff are marvellous here and you can not get a nicer place, they do their very best to look after me. Very, very happy at this home absolutely no complaints.’ ‘The staff make you feel life is worth living again.’ ‘The staff are excellent and very caring, nothing is too much trouble.’ The care plans are reviewed on a regular basis and evidence was seen that the residents are involved with their own care plans and sign them to confirm they agree with the plans. The home operates a key worker system and each resident has a photo of theirs on their notice board in their bedroom. The use of these notice boards is optional for each resident and they are removed if the resident does not wish to have one. Records confirm that health care needs are well met with residents having full access to all other professional health care specialists as required. All are registered with a local G.P and are well supported by the homes nursing staff. Optical, dental and chiropody needs are well met. All outcomes are appropriately recorded. Daily records are well maintained, dated and signed. The administration of medication was assessed and only qualified Nurses or senior care workers administer medications to the residents. Medication record sheets were dated and signed by staff and a list of staff specimen signatures was available for information. No errors were found on the recoding sheets. Medication is counted in and disposed of, if not required, in the correct manner. The home has a policy on privacy and dignity, which is strongly emphasised during induction and ongoing supervisions. Staff were seen to be respectful to residents and to use their preferred names. Residents confirm staff always knocked before entering their bedrooms and stated they felt respected at all times and that their dignity was always promoted, particularly when personal care is being delivered. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 13 Discussion took place with the manager regarding the care offered for residents with terminal illness. The home has a written policy and the ethos of the home is to be supportive and provide a pain free and comfortable time. Details of resident’s wishes are recorded to ensure they can be met at such difficult times. Attention is also paid to supporting relatives. The manager confirmed that the home would liaise with the GP’s and or the Princess Alice Hospice to ensure adequate pain relief. The majority of staff had recently completed Palliative Care training and bereavement counselling contacts can be provided for relatives as needed. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 14 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The arrangements for activities are very good ensuring service users social and cultural interests are catered for by the home. Residents are enabled to maintain contact with friends and family who are made welcome in the home. The opportunities for exercising choice are well developed ensuring service users can exercise choice over their lives. Meals at the home are well balanced and offer variety and choice. EVIDENCE: Discussion with the residents confirm they feel happy with the level of activities on offer and appreciated the effort made to ensure they all are given the choices over the range of activities. The home employs an activities coordinator who confirmed she spends time with each resident soon after admission and completes an assessment of likes and dislikes. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 15 The resident is asked what type of activities and hobbies they enjoy and where possible arrangement made to ensure these continue. The home offers a range of activities in the home including poetry readings, gentle exercises, games, and some arts and crafts. Arts and crafts are only offered to residents who have shown an interest. Some very pleasant artwork is displayed in the dining rooms. This is not an exhaustive list of activities. The residents confirm they do not like to play bingo but prefer other group activities such as quiz’s and crosswords. The home has a small van, which can take up to four ambulant residents out. If more places are required or the more dependent residents wish to go out, a specialist local taxi is used. Outside activities include going to shows, garden centres, shopping and general outings. Residents choose the shows they wish to see. Entertainers are invited to the home and the local school regularly comes in to entertain the residents. A Christmas Pantomime is booked. In the summer BBQ’s are arranged in the garden as well as luncheons and cream teas. Special anniversaries and birthdays are also celebrated. The home values equality and diversity and encourage residents to participate in community life. One resident confirmed she is enabled to attend a weekly club and that the home provides the transport. Comments made by residents include: ‘Nothing is too much trouble for the staff, they are exceptionally good and there is always something going on to do. Very happy with the level of activities - Thankfully we do not play bingo’ ‘We get to choose just about everything and are not all expected to do the same thing. Routines are very flexible and I can get up and go to bed whenever I like. Families can visit whenever they want and often stay for meals. That is very nice. It is lovely in the summer, the gardens are very pleasant and we like to have out meals out there. The staff make every effort to support us in a manner we like.’ Church services are regularly held and the local vicar ensures the residents can receive communion in the home. Residents confirm they can have visitors whenever they like and that often meals are taken with their families. Families are encouraged to remain as involved as possible with their loved ones. Residents are given the option to receive or refuse visitors as they wish. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 16 The residents receive a well-balanced menu and residents confirm that they always have a choice. One commented ‘ the food is very good and nicely cooked. I have never had anything that has been poor.’ Drinks are freely available throughout the day and meal times are flexible to suit the individual’s choices. Mealtime were describe by one resident as being “relaxed and unhurried and meals were nicely presented”. At a recent resident’s meeting, one resident stated she would like soft roes for tea and she confirmed they were on the menu the following week. The home can cater for specialist assessed diets and religious and cultural dietary needs are catered for. Fresh produce is available at all times Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by a robust complaints system and residents and relatives feel their views are listened to and acted upon. The home has robust adult protection policies and procedures to ensure that residents are protected from abuse. EVIDENCE: The home had a complaints policy, which is available in the policies and procedures file and the inspector noted complaints information in the service users guide. The manager stated the home had a complaints folder, which was sampled, and no complaints were recorded. The manager confirms she has an open door policy for residents, visitors and staff and prefers to discuss minor issue before they can escalate to a full complaint. The homes also has a folder with complimentary and thank you letters from relatives. Residents confirm they feel they can talk to anyone in the home and feel confident any issues raised would be dealt with efficiently. No complaints have been received by the Commission. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 18 The home has a policy on safeguarding adults and an up to date copy of the local authority (Surrey County Council) procedures on the protection of vulnerable adults. The inspector noted no concerns or allegations in respect of safeguarding adults were raised since the last inspection by the CSCI (Commission for Social Care Inspection). Staff displayed a sound understanding of Adult Protection and confirmed they had received formal training in this area. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 19 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, 20, 21, 22, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a clean, safe, well-maintained environment and have safe access to comfortable indoor and outdoor communal areas. The systems for hygiene control are well established and the home is clean and hygienic. EVIDENCE: The Red House is well maintained and has very pleasant gardens that are accessible for residents. There are ramps at the front door and handrails throughout. The home has an ongoing maintenance and renewal programme and the owners are currently reviewing some of the bedroom furniture. Some of this furniture is beginning to show signs of wear and tear. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 20 The home has purchased a loop system to better facilitate residents with hearing impairment, they are currently installing the system. Residents are encouraged to maximise their independence by having access to the range of specialist equipment supplied by the home. The home has invested in some new fire doors with all new intumescent strips to assist in fire safety. The handy man confirmed all doors now have three butts fitted, also for extra safety. A new CCTV system has been installed to improve external security. All bathrooms are spacious and clean and the home has sufficient toilets. The manager confirmed that all the bathrooms have overhead hoist and that two new one have been fitted to bedrooms. This means that there are currently five overhead hoists downstairs and five upstairs. Mobile hoists are also provided. Residents were seen to have specialist beds where required and had use of other specialist equipment such as cushions and wheelchairs. The bedrooms are well personalised and residents confirm they are happy with them. Residents also confirm they are encouraged to bring in personal photos and ornaments on admission. Telephones and television can be provided at the resident’s own expense. The home has a good set of policies and procedures for the control of infection and all staff have had infection control training this is reflected in their individual training records. Observations confirm the staff practice infection control measures by using gloves, aprons and washing their hands regularly to prevent the spread of infection in the home. The homes laundry is clean and tidy with two new washing machines being provided recently. Both are industrial machines with No Ozone medical sluices. On the day of the inspection the home was clean free from mal odour. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from staff that are well trained and competent to do their jobs and who enjoy good morale. Staffing arrangements provide for a suitable mixture of nursing, care, administrative, domestic, catering, and maintenance staff and ensure residents are well cared for EVIDENCE: On the day of the inspection there were sufficient staff on duty to meet the needs of the residents. The rota viewed confirmed this was the normal level of staff on duty. The home has the required amount of nursing hours as agreed at registration. When spoken with the residents all stated they felt the home was adequately staffed and they were rarely kept waiting long. Staff also commented that generally the staffing levels were good. As stated earlier in the report, resident satisfaction with the staff group is very high. The home very rarely uses agency staff thus ensuring residents are familiar with the staff and staff are familiar with the needs of the residents. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 22 Evidence was seen of a thorough training programme that incorporates all mandatory training as well as Dementia Awareness and Palliative Care. National Vocational Training(NVQ) is given a high priority and seven staff have achieved NVQ level 3 or equivalent, three have achieved level two and two are currently working towards their award. This is from a total of 15 carers. It is hoped that all staff will achieve at least NVQ level two in the near future. This level exceeds the requirement of 50 with NVQ level two or above. Two senior staff are qualified NVQ assessors. One of the Housekeeping staff is currently undertaking a NVQ in Hospitality. Staff commented that obtaining training was not difficult to obtain and that all applications are given consideration and are nearly always approved. Staff spoken with said the manager and owners are committed to providing well qualified staffing group. The home has a policy on recruitment, which is designed to ensure that the residents are safeguarded at all times. The manager stated the home has recently updated its induction checklist and all staff working at the home have induction training, which covers the values and principles of care, policies and procedures, health and safety and is dated and signed by the supervisor and employee. Three staff files were viewed and all contained all of the information required by regulation. All staff hold current CRB checks. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 23 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, 32, 33, 35, 36,and 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents benefit from having a manager who is supported well by senior staff in providing clear leadership throughout the home and by staff who demonstrate an awareness of their roles and responsibilities. The health, safety and welfare of residents and staff is promoted and respected. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 24 EVIDENCE: The home has a Registered Manager who provides management stability, leadership and direction to the staff team. The Manager has a professional nursing qualification, the RMA (Registered Managers Award) and the NVQ level 4 in Management and has over 38 years experience in the care. The inspector noted there are clear lines of accountability in the home and the Manager is aware of her role and responsibilities. The Deputy Manager provides strong support to the manager. Both the Manager and Deputy have continued to professionally develop by undertaking all mandatory training as well as additional training relevant to their roles e.g. Palliative Care, Dementia Awareness and Ear Irrigation training. The Deputy Manager has joined Continence Link Nurse Group and regularly attends meetings in order to update knowledge, share ideas and work towards improving practise. Staff confirmed they felt very supported by the Manager and owners and part of a strong team with high staff morale. The home was recently awarded ‘Investors in People Award’ which has given staff the opportunity to take ownership of individual projects and gather ideas for improvement. This had enabled teams to contribute to forthcoming plans, general improvements and their own personal development. There is a continuous self-monitoring process in place with services being audited and reviewed annually. The views of other visiting representatives from professional bodies, residents and their families are sought, the results are actioned and the finding displayed on the notice boards. This was confirmed by the residents. Regular residents meetings are also arranged and the minutes are available on the resident’s notice board. The Commission also received a very high level of comment cards returned from all interested parties. There were no negative comments made. Evidence was seen that the previous CSCI Inspection Report is available in the foyer. The Manager confirmed it is not the company’s policy to handle resident’s personal monies and encourages families to support where necessary. Secure facilities are available in each resident’s room and the home does have a small safe where small amounts of money and valuables can be stored. This is detailed on the individual care plan where necessary. Staff confirmed they receive regular supervision. This can be done at handover times, one to one sessions or group sessions. Staff confirmed they feel well supported and the manager has an open door policy to ensure any issues are dealt with efficiently and quickly. The management team is advised to record all supervision sessions fully and to date and sign them if agreed by staff. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 25 All policies and procedures relating to safe working practises are in place and all necessary health and safety checks are regularly undertaken. Due to changes in recent legislation the home has recently reviewed and updated their Fire Risk Assessment and evacuation plan and are currently working with the Fire and Rescue Service to make the necessary changes. The fire system is regularly checked and regular fire drills are undertaken. The home had a policy on COSHH (control of substances hazardous to health) and observations confirmed COSHH products were stored in a locked cupboard and the home had data sheets to promote the health and safety of staff and residents. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 26 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 3 4 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 3 3 STAFFING Standard No Score 27 4 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X X 3 X 3 Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP24 OP1 Good Practice Recommendations It is recommended that some of the bedroom furniture be renewed. It is recommended that the homes statement of purpose be updated to fully reflect Schedule one of The Care Home Regulations 2001. Red House (The) DS0000013362.V347091.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidston Office The Oast, Hermitage Court Hermitage Lane Maidstone Kent ME16 9BR 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) DS0000013362.V347091.R01.S.doc Version 5.2 Page 29 - 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!