Inspection on 14/02/06 for Redbond Lodge

This inspection was carried out on 14th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Redbond Lodge 09/09/09

Redbond Lodge 31/07/07

Redbond Lodge 07/08/06

Redbond Lodge 17/05/05

Redbond Lodge 20/01/05

Redbond Lodge 02/06/04

Redbond Lodge 16/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Redbond Lodge Chequers Lane Dunmow Essex CM6 1EQ Lead Inspector Diana Green Unannounced Inspection 14th February 2006 10:10 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 Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Redbond Lodge Address Chequers Lane Dunmow Essex CM6 1EQ 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) 01371 873232 01371 874451 redbond.lodge@runwoodhomes.co.uk Runwood Homes Plc Susan Lesley King Care Home 70 Category(ies) of Dementia - over 65 years of age (45), Old age, registration, with number not falling within any other category (70) of places Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 70 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 45 persons) The total number of service users accommodated in the home must not exceed 70 persons Staffing levels will be monitored for six months from 15 December 2003; they will then be reviewed with the inspector The registered person must not admit persons subject to the Mental Health Act 1983 or the Patients in the Community (Amendment) Act 1995 17th May 2005 Date of last inspection Brief Description of the Service: Redbond Lodge provides personal care with accommodation for up to 70 older people. The home is also registered to provide care to older people with dementia. Redbond Lodge is owned by a private organisation named Runwood Homes Plc. The home is located in the village of Dunmow, Essex. Redbond Lodge is a purpose built two-storey care home that has been extended and refurbished to provide 34 bedrooms on the ground floor and 36 bedrooms on the first floor with a dedicated dementia facility. The home has been adapted to meet the needs of service users with limited mobility and is fully accessible through a passenger lift and ramps. Redbond Lodge is easily accessible by road. Car parking is available in the car park to the front of the property. Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 14/02/06, lasting 7 hours. The inspection process included: discussions with the manager, care team manager, the laundry assistant, six care staff, twelve service users and five relatives; a partial tour of the premises including observations on residents’ bedrooms, bathrooms, the laundry, the sluice, medication/clinical room and communal areas and inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Eighteen standards were covered, and six requirements and one recommendation made. Action had been taken promptly to address previous requirements and recommendations. What the service does well: What has improved since the last inspection? The refurbishment off the home is now complete and the décor enhanced to provide a very pleasant, homely environment. The statement of purpose and service user guide have been reviewed to include the changes to the accommodation and increased number of registered beds and to reflect the developments in the services offered. Residents’ care needs are regularly Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 6 reviewed. Those residents transferred from another home during development work have been reviewed and more appropriate/alternative placements found where necessary. During that period the organisation’s Quality Team provided support in undertaking risk assessments. A new activities coordinator has been appointed and the provision of activities reviewed. All residents have a full social care assessment recorded to determine their preferences and ability to take part. All care staff now have some involvement in activities with residents. Staff who administer medication now receive training prior to assuming responsibility. Air conditioning has also been installed in the clinical/medication room. The laundry practices have improved and the laundry assistant has received infection control training. Two dishwashers have been purchased and installed in the unit kitchens. 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. Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 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 Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 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. Residents and their relatives have the information provided to enable them to make a decision prior to admission. The service operates a thorough and responsible pre-admission assessment process: care and attention is given to ensuring that the home can meet the individual’s needs, resulting in appropriate admissions. Visits to the home are encouraged prior to admission enabling prospective residents and their relatives to feel confident about their decision to move in. Individuals’ needs are being well met within the home. This home does not provide intermediate care. EVIDENCE: The statement of purpose and service user guide had been reviewed since the previous inspection. These documents now reflected the changes in accommodation and the increased number of residents at the home. Information on the range of care provided had been developed and updated and detail of the specific dementia care provision was also included. Residents Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 9 and their relatives spoken with confirmed they were aware of the statement of purpose and service user guide and had been provided with a copy. Four residents’ care files were inspected. All had a comprehensive assessment that included all elements of need as detailed under this standard. Copies of care management assessments were held on file on those sampled. All care files included a plan of care developed from the assessment. This home does not provide intermediate care. Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, & 9. There is a clear and consistent care planning system in place that provides staff with comprehensive information and ensures residents’ needs are appropriately met. The health care needs of service users are well met with evidence of good multi-disciplinary working taking place on a regular basis. The systems for administration of medicines are good with clear and comprehensive procedures in place. However adherence to procedures needs to be more robust to ensure residents’ safety is upheld at all times. EVIDENCE: Four care files were inspected. All contained care plans that covered all key needs (physical and social), provided good detail of the action required of staff to meet residents’ needs and were reviewed monthly. Residents and their relatives spoken with said they had agreed the care plan: their signatures also confirmed this. Risk assessments for moving and handling/mobility, pressure areas, continence needs and nutritional needs and falls were recorded in the files inspected and had been regularly reviewed. Daily records were detailed Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 11 and evidenced good monitoring of care needs with appropriate action taken where required. The home was well supported by the local GP practice who attended regularly to review residents. There was evidence of good liaison with district nurses who were in frequent attendance at the home to provide nursing treatment. Residents spoken with said that their personal care needs were met and that staff were very friendly and helpful. One resident said they were always respectful when providing their care. The records confirmed that residents had regular chiropody treatment and access to dental care, physiotherapy, occupational therapists and outpatients as required. The local community psychiatric nurse provided good support and reviews were undertaken as needed by the psycho-geriatrician. All medication was stored in the clinical/medication room. Air conditioning had been installed sine the previous inspection. Room and refrigerator temperature monitoring was in place, however this was only undertaken during the night. Advice was given to also record temperatures at times during the day. The home had medication policy and procedures but these were not available in the medication room for staff guidance. Care team managers administered all medication at the home and had all received appropriate training. Medication was supplied through the local pharmacist and appropriate ordering and disposal procedures were followed. Medication administration records (MAR) were generally well recorded. Care team managers spoken with were aware of the need to monitor omissions of signature and to record the reason, however this was not always actioned. The administration of temazepam was well monitored and recorded. Advice was given to ensure that where this was treated as a controlled drug (acknowledged to be good practice), there is a need to record as such. This entails recording the address on receipt and disposal. Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 14. Full care staff involvement in the provision of activities enables residents to have a comprehensive and purposeful life. Residents at Redbond Lodge are enabled choice and control in their daily lives as far as possible. EVIDENCE: The home had a new activities coordinator who had been appointed since the previous inspection. A range of group and individual activities were displayed for information and photographs of past activities were also displayed throughout the home. All residents had an activities’ assessment undertaken and recorded. This included a life history, residents’ preferences, hobbies, spiritual needs and an assessment of mobility/activities of daily living that included any concerns or risks. All care assistants had been provided with information detailing what activities they could also undertake with residents, e.g. board games, reminiscence, hand massage, sing-a-long, ball games etc. Some residents were observed to be enabled a choice of eating in the dining room or their own rooms. Those spoken with said they also had a choice of time in getting up, going to bed and in taking part in activities. Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 13 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): 18. Appropriate policies, procedures and practices were in place to promote the protection of residents from abuse. The organisation actively promoted awareness of protection issues through staff training, recruitment practices and respecting individual rights. EVIDENCE: The home had a comprehensive policy and procedures for the protection of vulnerable adults. All staff had received relevant training and been provided with guidance published by the EVAPC (Essex Vulnerable Adults Protection Committee) for their information. The manager was well informed on the procedures to be followed in the event of any allegations. Records inspected showed that appropriate pre-recruitment checks on new staff were undertaken prior to appointment (see standard 29). Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 14 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. Redbond Lodge is safe, well maintained and has a homely environment. The home was clean and hygienic but the lack of facilities for staff hand washing in en-suites compromises infection control standards. EVIDENCE: A partial inspection of the premises was made that included communal areas, a number of residents’ rooms, the sluices, bathrooms and the laundry. Some areas of the home required attention to ‘make good’ following the recent refurbishment and this was being actioned. Communal rooms were clean and well decorated and furnished to provide a homely environment for residents. Residents spoken with said their rooms were always kept clean. A sensory garden was planned for residents and other quadrangle gardens provided access for residents. Records provided evidence that the building complied with the requirements of the local fire and environmental health departments. The home was clean and hygienic throughout with no odorous smells. The infection control practices in place were generally safe. However liquid soap Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 15 and paper towels were not available in all en-suite rooms, although antiseptic hand wash gel had been made available and a clinical waste bin was not locked. The home had two sluice disinfectors, one on each floor of the premises that were well maintained. The laundry was equipped as required and very well organised. Laundry and sluice facilities were located away from areas where food was prepared or eaten. Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 16 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 & 29. Staffing levels are not adequate at all times to ensure the safety of residents. Recruitment practices for staff were thorough and protected service users. EVIDENCE: There were sixty-seven residents at the home. Staffing numbers appeared to meet the minimum levels agreed with the CSCI, and from inspection of the staff duty rota and discussion with staff and residents, there was evidence that staffing levels were well maintained. However, there was no flexibility in staff deployment and these levels were not adequate to ensure the safety of residents during the lunch-time meal: in one unit some residents were left unsupervised when the one designated care assistant was assisting another resident with toileting. The dependency needs of several residents in the home required ongoing supervision with one resident requiring one to one supervision, reducing the overall number of care staff available to eight. The staffing levels should therefore have been increased accordingly. The files of three new staff members were inspected: these contained evidence that all the required checks had been obtained (two satisfactory references, POVA checks) and copies of birth certificates, passports, photographs obtained before the individuals commenced employment at the home. A CRB disclosure had been obtained for one member of staff and requested for the two remaining staff but not yet received. All had received a statement of terms and Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 17 conditions of employment. All staff were provided with a copy of the General Social Care Council Code of Conduct on appointment. Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 18 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, 33, 35, 37 & 38. The home is well managed and run in the best interests of service users. The systems for service user consultation are good with sound evidence that indicates that their views are sought and acted upon. The robust systems in place assure residents their financial interests are safeguarded. EVIDENCE: The registered manager had managed the home for several years and was currently undertaking NVQ level 4 training which she expected to complete by 31st march 2006. Residents and relatives said they found the manager very helpful and approachable and staff said they felt supported by her. The organisation’s annual audit report found that the management of the home Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 19 had improved from the previous year, reaching a considerably higher score that the company average. The home had a quality assurance framework in place that included distribution of service users’ questionnaires. A catering survey had been held since the previous inspection, the findings of which were being acted upon. An annual report/development plan was produced for the home. Policies and procedures inspected were regularly reviewed and action from inspection reports was progressed within timescales as required. There was evidence from discussion with residents, the registered manager and staff and previous knowledge of the home that Redbond Lodge was run in the best interests of service users. All service users had an advocate/representative to manage their finances on their behalf. Personal allowances were held for some service users and accurate records were maintained to ensure the safe keeping of money held on their behalf and to ensure they received the appropriate allowances. Records required by regulation for the protection of residents viewed on this occasion included a sample of: staff rotas; staff recruitment records; residents’ care plans; daily records (including weight monitoring); medication records; records of complaints and accident records. Where relevant, records have been commented on under the relevant standard, but all were generally well maintained and up to date. However care records were observed stored on a shelf in an open office that was accessible to other residents and visitors. The home was in the main safe, well managed and had the relevant health and safety practices in place. There was evidence from observation, inspection of the records and in discussion with staff and residents that the manager aimed to ensure the health and safety of staff and residents. However a clinical waste bin stored externally was unlocked. The premises were secure and there was evidence of risk assessments of the premises having been undertaken and appropriate action taken. Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 20 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 3 8 3 9 2 10 x 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 x 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 4 x 2 3 Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 21 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 OP9 Regulation 13(2) Requirement The registered person must ensure that the omissions of signature are monitored and the reason recorded on the MAR sheet. The registered person must ensure that the records of the receipt and disposal of Controlled Drugs made in the Controlled Drug Register carry the name and address of the supplier or recipient on disposal. The registered person must ensure that paper towels and liquid soap are available for staff hand washing in en-suites. The registered person must ensure that clinical waste bins are locked at all times. The registered person must ensure that staffing levels are adequate at all times to meet residents’ needs and ensure their safety. The registered person must ensure that residents’ care files are kept secure at all times in accordance with the Data Protection Act 1998. DS0000017917.V283732.R01.S.doc Timescale for action 31/03/06 2. OP9 13(2) 31/03/06 3. OP26 13(3) 31/03/06 4. 5 OP38OP26 OP37 13(4) 18(1) 31/03/06 30/04/06 6 OP37 17(1)(b) 30/04/06 Redbond Lodge Version 5.1 Page 22 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 OP9 Good Practice Recommendations The registered person should ensure the drug and room storage temperatures are recorded at times during the day and night. Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Redbond Lodge DS0000017917.V283732.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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