Inspection on 31/07/07 for Redbond Lodge

This inspection was carried out on 31st July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Redbond Lodge 09/09/09

Redbond Lodge 07/08/06

Redbond Lodge 14/02/06

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 Key Unannounced Inspection 31st July 2007 09:30 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.V347669.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. Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 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 www.runwoodhomecare.com 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.V347669.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 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 The registered person must not admit persons subject to the Mental Health Act 1983 or the Patients in the Community (Amendment) Act 1995 7th August 2006 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. The fees range from £427.00 -£580.00 weekly. Additional costs apply for chiropody, toiletries, hairdressing and newspapers. This information was provided to the CSCI on 31/07/07. Redbond Lodge DS0000017917.V347669.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 undertaken on the 31/07/07 and lasted 7 hours. The inspection process included: discussions with the manager, the laundry assistant, eight residents, five care staff, four visitors and feedback from relatives and health and social work professionals; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas, the kitchen, the laundry and the sluice-rooms; an inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Evidence was also taken from completed surveys and the Annual Quality Assurance Assessment completed by the management of the home and submitted to the CSCI. Twenty-five standards were inspected and two requirements and four recommendations made. The manager and staff were welcoming and helpful throughout the inspection. What the service does well: Redbond Lodge has a welcoming and relaxed atmosphere that is reassuring to visitors. High standards are promoted across all services. The premises are clean, well furnished and well maintained. Attention has been taken to ensure residents are happy and secure in their environment by encouraging them to personalise their rooms and consulting with them to add personal touches in bathrooms and communal rooms. The manager and staff have coped well with the challenges of a substantial increase in size of the home together with transfer of residents from another home. The home has settled well and a stable and effective staff team have been established that are well supported by the manager and senior staff. The standard of health and personal care are good and there is good monitoring of care needs with appropriate and prompt referral to health and social care professionals. Residents are able to participate in a wide range of social activities with a strong emphasis on community involvement. There is good communication with relatives and residents said they felt well supported by the friendly staff. Typical comments made were: “I am very happy here and appreciate the staff who work so very hard”; “It is a good home”; “the staff are friendly and supportive and follow through instructions given”; “an excellent home”. Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Redbond Lodge DS0000017917.V347669.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 Redbond Lodge DS0000017917.V347669.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): Quality in this outcome area is excellent based upon sampled inspected standards 1, 3, & 6. Residents and their representatives were very well informed and had their needs fully assessed prior to moving in to the home. This home does not provide intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a recently updated statement of purpose and a service user guide/welcome pack (viewed in several residents’ rooms). Relatives spoken with confirmed that a copy of the statement of purpose had been made available to them. Relatives who completed surveys confirmed they were able to view the home and one said they visited several times before making a decision. Another spoken with said they received plenty of information and were visited in hospital where they were consulted on how they would like their care arranged. A copy of the most recent inspection report was on display Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 9 in the entrance of the home together with a range of information on services to ensure potential residents and their representatives were well informed. Seven residents’ files were sampled. All had an assessment of needs undertaken by the manager/deputy manager prior to admission that included all elements as detailed under this standard. The assessment comprised a tick box that was used to inform the care plan. Care management assessments were obtained where relevant and held on file. Where information was incomplete this had been followed up, discussed with health and social care professionals and detailed in the assessment. Pre-assessments identified residents’ individual needs. Information received from the manager included plans to develop a local policy on cultural and religious beliefs and provide further staff training to ensure their understanding of cultural and religious beliefs. This home does not provide intermediate care. Redbond Lodge DS0000017917.V347669.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): Quality in this outcome area is excellent based upon standards 7, 8, 9 & 10. The standards of care planning and access to healthcare were good with residents’ privacy and dignity needs consistently met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Seven care plans were reviewed during the site visit. All were person centred and comprehensively recorded. Risk assessments undertaken included individual risks for falls; moving & handling; mental health status; dependency assessment; continence; skin integrity and nutrition/weight monitoring. All risk assessments and care plans had been reviewed regularly. Daily records were comprehensive and detailed good monitoring of needs and appropriate action taken as relevant. Residents and their relatives spoken with confirmed they were fully involved in the development of their care plan. Completed surveys received from relatives indicated that very good standards were set. The records confirmed evidence of good monitoring of health care needs with prompt referral to GPs and health care professionals and appropriate follow up Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 11 action being taken. The home had positive relationships with the local GP practice whose representative attended regularly. There was evidence of access to outpatient services, dental, chiropody and annual eye tests with some attending their own optician as they chose. Positive feedback was received from a GP and a district nurse that staff always followed instructions given. Residents who completed surveys stated, “immediate medical attention and good nursing care is provided when I need it”; “staff are very good with medical help”; “I am very satisfied with the care”. One concern was raised indicating that care staff do not always report medical conditions promptly to senior care staff. This was also supported by comments from a health professional that communication at handover meetings could be improved. It was good to see staff’ rapport with residents throughout the day i.e. explaining what they were going to do when providing personal care, discussing the weather, where they were going to take them and what activities were being arranged etc. The home had a policy and procedures for the safe ordering, administration recording and disposal of medication. Local procedures for the home were also available for staff guidance. Medication was administered by care team managers who had received training and been assessed as competent to give medication. A current list of those staff signatures and initials was available. There were two clinical rooms, one on each floor of the home where medication was stored. The ground floor medication room was inspected. The room had an air conditioning unit installed and daily monitoring and recording of room temperatures was undertaken and recorded. A drug refrigerator and a domestic type fridge were stored in the room. Monitoring and recording of temperatures was undertaken and recorded for the drug fridge only. Medication was stored in one large trolley that was secured to the wall and in a large storage cupboard. Controlled drugs were stored separately and appropriately recorded. Records sampled were generally well recorded. However care team managers were signing to confirm that prescribed creams had been given when these were not administered by them but by care staff. This is contrary to regulations and Runwood Homes’ procedures. The medication trolley was also observed left open and unsupervised for several minutes during a medication round. Care management feedback indicated that residents were encouraged to self medicate where able. This was confirmed from the risk assessments viewed. Regular reviews undertaken by GPs were also evident. Staff were observed to knock before entering residents’ rooms. Residents and their representatives who completed surveys stated that staff were polite, friendly and always knocked before entering. One resident spoken with said that staff had asked them how they wished to be known. There were no shared rooms. All residents’ rooms were single en-suite accommodation and treatment was therefore provided in their room ensuring their privacy was respected. Redbond Lodge DS0000017917.V347669.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): Quality in this outcome area is good based upon standards 12, 13, 14 & 15. The social and therapeutic activities offered at the home met residents’ cultural needs and expectations and enhanced their daily lives. Visitors were warmly welcomed into the home. The home provided residents with a well-balanced and nutritious diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a full time activities coordinator who arranges a full and varied programme of activities during the week (e.g. games, quizzes, dominoes, bingo, reminiscence, bagatelle, bowls, arts and crafts, entertainers, etc.). Care staff that had received training in dementia care also provided activities. Activities programmes and local information was displayed on notice boards in the home. A monthly newsletter had also been introduced for residents, relatives and the local community. Residents’ files viewed contained a social history or family tree, providing a good profile on the person, and information on their past interests. Care plans provided evidence that residents’ preferences/abilities had been discussed with them. Records made in daily notes included evidence that residents had been encouraged to join in activities and where they had taken part the outcome was also recorded. Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 13 Individual activities and outings were also arranged including access to local concerts and shows. It was a warm sunny day and several residents had been taken out to the shops and others were observed sitting in the quadrangle garden talking with visitors and staff and enjoying iced lollies. The majority of feedback received in completed surveys from residents and their representatives was positive, with most stating there were always suitable activities to meet their needs. One residents stated ”we have a good choice of games, painting, drawing and musical evenings”. A relative said that the staff had got their loved one interested in things they had not done for years. Another said that hearing problems inhibited their relative fully taking part in activities, particularly in-group activities, indicating there was a need to further develop activities for the hearing impaired. Residents said that their friends and relatives could visit at any time, and they could meet with them in private in their rooms. One resident said they had friends that come and take them out. Representatives of different faiths attended the home as relevant. Evidence that some local community groups had visited the home at Christmas (e.g. bell ringers, local school children carol singing) was seen in the large portfolio that included photographs of past events and was displayed in the entrance hall. Relatives said that all staff were very welcoming and they were “very polite to all visitors”. Residents spoken with were clear that they had choices about their daily life in the home, especially in regard to where they spent their day, ate their meals etc. Some residents had a choice of their own hairdresser, chiropodist and optician, with some attending their own optician outside the home. The menu was clearly displayed in the home and residents are enabled a choice of cooked meals. Many of the rooms seen were well personalised, showing that people could bring their own possessions into the home with them. One married couples’ needs for autonomy over their lives were promoted through the accommodation provided (e.g. two adjoining rooms, used as bedroom and lounge). Information on advocacy services was included in the statement of purpose and available in the home. The home had links with the Alzheimer’s Society and advocates were arranged for residents without a relative. The menu of the day was on display for residents’ information. Menus were planned over a four-week period and demonstrated an appropriate range of well balance meals with choices accommodated. Meals were served in the main dining room where the majority of residents were encouraged to eat. Residents from Bluebell and Sweet Pea Units were served lunch from a heated trolley in their own units where supervision and assistance with eating was provided. However in Jasmine Wing where there were three residents, two of which were eating lunch in their rooms, there were no staff available in the event of an emergency. Staffing levels at the last key inspection were also found not to be adequate to safely supervise residents. (see standard 27). Tables were nicely laid with tablecloths, cutlery, serviettes and condiments. The main meal served on the day of the inspection comprised turkey stew or sausages and onion Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 14 served with mashed potatoes, cauliflower and peas. The lunch was served in Sweet Pea from a hot food trolley following that served to residents in Bluebell Wing. The meal was sampled: the meat was hot but the vegetables were lukewarm. This appeared to be due to the numbers of staff available to in serve, assist residents with eating and take the trolley to Sweet Pea. Hot drinks were seen being served during the day, and water jugs were seen in residents’ rooms. Residents spoken with were generally positive about the meals served at Redbond Lodge. Comments received included: ”the meals are very good”; “There is a good variety of food at tea time. We have crumpets and jacket potatoes sometimes and there is always home made soup”. Many residents were also seen enjoying the social interaction during breakfast and lunch served in the main dining room where there was no pressure on time. Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent based upon standards 16 & 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. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had a complaints procedure that included the timescales within which complainants can expect a response and advised them of their right to refer to the CSCI at any stage. The procedure was included in the statement of purpose and displayed in the entrance of the home. Sixteen complaints had been received since the previous inspection. All had been investigated thoroughly. All concerns, complaints and allegations were well monitored and used to improve standards. For example, providing more food choices and developing links/obtaining support from the falls assessor employed by the local primary care trust. The manager said that residents were openly encouraged to talk about their concerns during the residents meetings, monitoring visits by council and the area manager and during the yearly quality audit. Residents and their relatives who completed surveys and those spoken with said the manager and staff kept them informed and were very responsive to any requests or concerns raised. One relative stated that they hadn’t needed to make a complaint and were very impressed with the standard of care. The home had a suggestion box in the reception area where residents/ Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 16 families can leave anonymous complaints if needed. One relative said they completed several compliment reports on the home. The home had comprehensive policy and procedures for safeguarding vulnerable adults. All staff had received relevant training. From previous knowledge of the home it was evident that the manager and senior staff were skilled and experienced 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). Information received from the manager stated that staff are reminded during supervision and team meetings about whistle blowing and abuse. There had been no allegation of abuse made since the previous inspection. Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent based upon standards 19, 22 & 26. Redbond Lodge was safe, well maintained and had a homely environment; residents’ rooms were individually furnished and equipped for their safety, comfort and privacy. The home was clean and hygienic with safe infection control practices that were well adhered to. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial inspection of the premises was made that included communal areas, several bathrooms, a number of residents’ rooms, the kitchen, clinical room, the sluice and the laundry. The home was in a good state of maintenance and decoration and was furnished in accordance with the client group. The spacious entrance hall had notice boards with full information displayed. The ambience of the home was relaxing with easy listening music playing in the hall and communal rooms and was very reassuring to visitors. Communal areas had ornaments and pictures and bathrooms had been personalised in conjunction Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 18 with the residents wishes, for example with seaside themes. Efforts had been made to ensure the front gardens were tidy and attractive. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. The home had passenger lifts to enable access throughout the premises. There were grab rails, and aids in bathrooms, toilets and communal rooms to meet the needs of residents. Assisted baths and toilets were provided and the home was fully accessible to wheelchairs. Call systems were provided throughout all individual and communal rooms. Pressure relief equipment was assessed and provided by the district nursing service to meet the needs of residents. All equipment was serviced as per manufacturers recommendations and confirmed from the records inspected. There were policies and procedures for infection control available for staff guidance and all staff received training during induction and at regular updated sessions. The home was cleaned to a high standard throughout. Systems were in place for monitoring and shampooing carpets to ensure the home remained odour free. A new replacement carpet had been ordered for one room. The laundry room was clean and well organised, with separate areas for clean and dirty laundry. There were two washing machines and two driers that were in working order. Sluice facilities were located on each floor of the home. Systems were in place to minimise risk of infection via the use of red bags for any laundry soiled by body fluids, placed directly in the washing machines and washing machines had the capacity to carry out sluice wash cycles. One pedal bin located in the clinical room required replacement as the mechanism operating the lid was not functioning. Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 adequate based upon standards 27, 28, 29 & 30. People living at Redbond Lodge can expect to be cared for by a well-motivated and skilled staff team but staffing levels are not always sufficient at key periods to ensure their safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Redbond Lodge have an enthusiastic and motivated staff team. There is low turnover of staff, with no agency staff being regularly employed and high staff morale. Feedback received from the care team managers indicated they took pride in their work, felt supported by the manager and had good job satisfaction. Information received from the manager indicated that the skills and experience of staff on each shift was varied to ensure good skill mix and monitoring of care provision. Staffing levels were appropriate to meet the needs of residents with exception during the lunch period when there was no flexibility to enable appropriate monitoring of residents (Jasmine Wing). This was also highlighted at the last key inspection. A review of staffing levels needs also to take account of other duties undertaken by care team managers (rounds with GPs, care planning, staff supervision etc.) and that administering medication means that they are not available to provide personal care for approximately 7 hours in a twenty-four hour period. The home employs sufficient domestic, laundry and catering staff to ensure the cleanliness and smooth running of the home. A full time maintenance person is also employed. Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 20 Feedback from residents and their relatives indicated they were confidant in them. Comments included: “staff are friendly, helpful and patient”; “the staff are dedicated and always attentive”; “the current staff do a good job and run a smooth ship”; “all the staff including domestics are willing to give me help when I need it”. The home had 8 care staff with NVQ level 2 qualifications and one with NVQ level 3. A further 4 staff had registered to undertake NVQ level 2. The percentage of staff with NVQ level 2 training was therefore less than 50 needed to meet the standard. Eight staff from overseas (4 qualified nurses and 4 physiotherapists) were also employed at the home. The manager reported they had been unable to secure funding for NVQ training for these individuals. The recruitment files of four recently employed staff were inspected. All had evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and copies of birth certificates, passports, and photographs obtained before the individuals commenced employment at the home. All had received a statement of terms and conditions of employment. The manager reported that all staff received induction to Skills for Care Standards (records were not inspected). The home had an established training programme. Feedback received from care team managers indicated that ongoing training and development enabled them to deliver the best possible care. The training records seen confirmed that staff had completed training on Protection of Vulnerable Adults, fire safety, and moving and handling. Training had also been provided on first aid, health and safety and food hygiene. Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good based upon standards 31, 33, 35, 37 & 38. The manager is supported well by senior staff in providing clear leadership throughout the home with all staff demonstrating a good understanding of their roles and responsibilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is skilled and experienced, having managed Redbond Lodge for a number of years. She has completed the Registered Managers Award and there was evidence of regular updated training having been undertaken. Discussion with care team managers and surveys completed by them indicated that the manager strived for excellence whilst also providing good leadership and direction for staff. Surveys completed by residents and Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 22 their relatives stated that there is an “excellent open door policy to enable residents/ families to speak with the manager” and “this is an excellent home”. There is a corporate quality assurance programme that includes an annual audit of the home that is used to develop an annual plan. The manager reported that preparation was underway for the annual audit by the use of an audit tool for checking service prior to the visit by the Quality Team. Internal audits undertaken comprised health and safety, pharmacy and catering. The home monitored all complaints and compliments and also had a suggestion box for residents and visitors. Relatives meetings are held monthly where issues, for example the catering survey are discussed. Visits required under regulation 26 had been undertaken and reports sent to the CSCI. The home has secure facilities for the storage of any money looked after on behalf of residents. There were clear individual records of this, with receipts kept and cash held in individual zipped ‘pouches’. Four residents’ records were inspected, and records, receipts and cash all balanced. The administrator explained that representatives of the organisation also undertook audits. Records held on behalf of residents were kept up to date and were stored safely in secure facilities. Records viewed at this inspection included: the statement of purpose, service user guide, care plans, medication records, staff recruitment and training records, maintenance records, accidents/incident records and fire safety records. The home had a health and safety policy manual and the records confirmed that staff had attended relevant health and safety training. Evidence of a sample of records viewed showed that there were systems in place to ensure the servicing of equipment and utilities and there was evidence of appropriate weekly and monthly internal checks being carried out (e.g. checks on fire equipment and door closures, fire alarms and emergency lighting, hot tap water temperatures, etc.). All accidents, injuries and incidents were wellrecorded and appropriate action taken. Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 4 X 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X 3 X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 3 3 Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 To ensure the safe storage and administration of medication: 1.The medication trolley must be kept locked when not supervised. 2. Administration of prescribed creams must be confirmed by the signature of the person who administers it. 2. OP37 18(1) Staffing levels need to be 31/08/07 adequate at all times to meet residents’ needs and ensure their safety. This is a second repeat requirement. Timescales of 30/04/06 & 31/08/06 not met. Timescale for action 31/08/07 Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP8 OP26 OP28 OP30 Good Practice Recommendations To ensure all residents are able to participate in meaningful activities, activities should be further developed for residents with a hearing impairment. To ensure safe disposal of clinical waste, a new foot operated bin should be provided in the clinical room. To ensure residents are cared for by skilled care staff 50 of care staff should undertake NVQ level 2 training. To ensure the specialist needs of residents are appropriately met, care staff should receive training on care residents who have seizures. Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Redbond Lodge DS0000017917.V347669.R01.S.doc Version 5.2 Page 27 - 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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