Inspection on 07/08/06 for Redbond Lodge

This inspection was carried out on 7th August 2006.

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 31/07/07

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 Final Unannounced Inspection 7th August 2006 09:00 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 Redbond Lodge DS0000017917.V307613.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.V307613.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 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.V307613.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 14th February 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 £482.00 -£508.00 weekly. Additional costs apply for chiropody, toiletries, hairdressing and newspapers. This information was provided to the CSCI on 8/08/06. Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place on the 47/08/06, lasting 7.5 hours. The inspection process included: discussions with the registered manager, eight care staff, the laundry assistant, cook, kitchen assistant, ten residents, two relatives and feedback from 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 sluicerooms; an inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Twenty-six standards were covered, two were commended and five requirements (including one repeat) and one recommendation made. The manager, deputy manager and staff were welcoming and helpful throughout the inspection. Typical comments received from residents and relatives were: “the manager is excellent and the staff, particularly the senior staff are very good”; “I’m always welcomed into the home at any time and offered a cup of tea”; “ they do their best for you at all times”;” I’m quite content living here”; ”staff do their best”; “a lack of available staff can cause problems but they always try to resolve this”. What the service does well: Redbond Lodge provided a welcoming, homely environment. The home had been refurbished and decorated to a high standard. Communal and individual rooms were pleasantly furnished and residents were enabled to bring their own possessions into the home. The home was well managed, well maintained and despite being a large home, the atmosphere was relaxed. Standards of cleaning were good and generally well monitored. The home provides care for residents with dementia and appropriate signs were provided for their needs. Residents’ personal care needs were well met and there was good access to health care services and good liaison with GPs and district nurses. Medication reviews were regularly undertaken. Care plans were regularly reviewed and provided good instruction to staff. Care staff were friendly to residents but also treated them with respect. The manager operated an open management style and staff were well supervised. Communication with relatives was good. The manager was well known to both residents and their relatives and always available to them. Residents were protected by the homes’ recruitment procedures and abuse procedures. Residents’ rights were upheld wherever possible, including their right to be treated at the home rather than hospital. Redbond Lodge DS0000017917.V307613.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. Redbond Lodge DS0000017917.V307613.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.V307613.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Residents had the information needed to make an informed decision. The assessment process was robust and ensured residents’ needs could be met. This home does not provide intermediate care. EVIDENCE: The home had a statement of purpose and service user guide that reflected the aims and objectives of the home. The statement of purpose was made available to prospective residents and was displayed in the entrance of the home together with the service user guide and previous inspection report. 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.V307613.R01.S.doc Version 5.2 Page 9 Redbond Lodge DS0000017917.V307613.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. 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 were aware of the care plan: their agreement should also be confirmed by signature where possible. 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 Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 11 regularly reviewed. Daily records were detailed 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 clinical/medication room, one on each floor of the home. The ground floor medication room was inspected. Air conditioning had been installed sine the previous inspection. Room and refrigerator temperature monitoring was in place. Medication was stored in a trolley that was secured to the wall as required and in a storage cupboard for controlled drugs. The home had medication policy and procedures that were available 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 had not been followed for one resident’s prescribed creams. A second resident who had chosen to self medicate for inhalers had a risk assessment but this had not been reviewed since 28/04/05. The administration of temazepam was well monitored and recorded. Advice previously given to ensure that controlled drugs had the name and address recorded on receipt and disposal had been followed. Regular medication reviews were undertaken. Action had been taken to ensure there was no over prescribing of anti-psychotic medication. Redbond Lodge DS0000017917.V307613.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. 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. EVIDENCE: The home’s activities coordinator who had been in post a few months had recently left employment. However all care assistants had received training and the manager said that an administrative assistant was also helping with activities. Information on activities was displayed on notice boards throughout the home. This also included links with local community groups including the Alzheimer’s Society. The home also has links with the local mayor who had invited residents to shows at the local ‘Folks Hall’; Trident scheme; local schools and had access to the community bus scheme for residents. Shopping trips, visits to coffee shops and local carnivals had also been arranged for residents. Information on activities was included in the statement of purpose and those provided included quizzes, dominoes, bingo, puzzles, cards, reminiscence, bagatelle, bowls, darts, and handicrafts. All residents had an assessment undertaken and recorded. This included a life history, residents’ Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 13 preferences, hobbies, spiritual needs and an assessment of mobility/activities of daily living that included any concerns or risks. Visitors were observed to come throughout the inspection and those spoken with said they were always made to feel welcome at the home. Residents spoken with said they could choose whether to take part in activities and to go on outings and in what clothes to wear. The majority of residents were observed to eat in the dining rooms of the home and some were also observed to have their breakfast in their own rooms and some ate at a later time when they got up. 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 staffing levels were not adequate to safely supervise residents. (see standard 27). New menus had been developed for the organisations’ homes with the assistance of a dietician. The menus observed were balanced and nutritious and detailed the nutritional values for each day and week. The lunchtime meal of gammon, mashed potato, carrots and cauliflower was sampled and the meat was tender. An alternative choice of lasagne was also provided. Residents spoken with said they enjoyed the meal. However feedback was also received that some residents found the new meals too spicy. Care plans and nutritional records inspected detailed weight monitoring and action taken as needed. Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a site visit to the service. 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 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. Four complaints had been received since the previous inspection. All had been dealt with in a robust manner. Concerns were documented and trends identified. All allegations, concerns and complaints were used to improve standards, which is acknowledged to be good practice. The home had comprehensive policy and procedures for safeguarding 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. Recent events demonstrated that the manager was skilled and experienced on the procedures to be followed in the event of any allegations. Positive feedback had been received from members of the multi-agency team to that effect. Records inspected showed that appropriate pre-recruitment checks on new staff were undertaken prior to appointment (see standard 29). Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 15 Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. 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 in the main well adhered to. 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. The premises were well maintained. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. The home had grab rails, ramps, hoists and other mobility equipment to meet the needs of residents. Wheelchairs were provided and were well maintained. Pressure relief equipment was assessed and provided by the district nursing service to meet the needs of residents. Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 17 The premises were observed to be clean and hygienic throughout, although some shortfalls were evident in the kitchen i.e. wet mop stored upside down; inadequate cleaning of degreaser dispenser; paper towels and liquid soap not available in the designated facility. Opened food observed in the fridge was not labelled with the date of opening. Two residents’ rooms had a malodorous smell. The manager said that due to staffing problems that morning domestic staff had not had time to shampoo the carpets as they would normally. Care plans confirmed that the residents’ needs were being addressed. The laundry facilities comprised a clean and dirty area and a separate room for drying clothing. The laundry was clean and appropriately equipped and was well organised. Appropriate hand washing facilities were in place and safe practices were observed with the exception of some staff not wearing designated aprons when serving meals. Some waste bins were not footoperated as required for disposal of clinical waste. Action had been taken to ensure all clinical waste bins were locked. Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. Staffing levels are not sufficient at all times to ensure the safety of residents. Staff recruitment practices were thorough and protected service users. Substantial investment in training had been made that provided staff with appropriate skills to care for residents. EVIDENCE: There were 69 residents including 2 residents in hospital. Staffing levels were confirmed at: AM – 2 care team managers 9 care assistants PM – 2 care team managers 8 care assistants Night 1 care team managers 4 care assistants. The staffing levels were not adequate to meet the needs of all residents, and left no flexibility for urgent situations, especially during staff breaks. Three residents were observed sitting in wheelchairs until after lunch as staff said they did not have time to transfer to appropriate chairs. One care assistant was supervising five residents, one of whom displayed aggressive behaviour. During the morning this resident had been left unsupervised when another needed assistance with personal care. The manager said that care staff were directed to call for assistance from a care assistant in the adjoining unit. However this was not practicable. Seven residents with dementia were left unsupervised when the two care staff on duty were assisting another resident in a bathroom. The manager said that an increase in staffing levels had been agreed. Feedback from residents indicated that there were insufficient staff on Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 19 duty, some said they had to wait for up to one and a half hours to be assisted to get up in the morning and that staff were unavailable to assist at specific time. The home had eight staff who had NVQ level 2, seven who were undertaking NVQ level 2 and two who were undertaking NVQ level 3 training. The staff files confirmed that all new staff received induction to Skills for Care standards. The files of four recently employed staff were inspected: these contained evidence that all the required checks had been obtained (two satisfactory references, CRB/POVA checks) and evidence of ID had been obtained before the individuals commenced employment at the home. All had received a statement of terms and conditions of employment. All staff were provided with a copy of the General Social Care Council Code of Conduct on appointment. The home had a comprehensive training programme in place. Records summarising training were seen, and showed that most staff were up-to-date with all mandatory training including health and safety, fire safety, basic first aid and moving and handling. Training had also been provided in dementia care, protection of vulnerable adults, food hygiene for cooks and control of substances hazardous to health. Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Redbond Lodge is well managed and run in the best interests of residents. EVIDENCE: The registered manager is skilled and experienced, having managed Redbond Lodge for a number of years. She had recently completed the Registered Managers Award and there was evidence of regular updated training having been undertaken. From discussion with staff, residents and relatives it was evident that they found the manager very helpful, approachable and quickly dealt with any issues. The home had a quality assurance framework in place that included an annual quality audit from which an annual plan was developed. Progress from this was monitored by regular monthly visits undertaken by a senior manager and a six-month quality monitoring review. Complaints/compliments were monitored Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 21 with appropriate action taken. The home obtained feedback from staff, residents and their relatives through regular meetings, a suggestion box and surveys. There were plans to undertake a catering survey and a leaflet to obtain feedback from residents receiving respite had also been developed. 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 held on behalf of residents were kept up to date and stored safely in secure facilities in a locked office in accordance with the Data Protection Act 1998. Records viewed at this inspection included: care plans, medication records, statement of purpose, service user guide, staff recruitment and training records, maintenance records, accidents/incident records and fire safety records. From discussion with the manager it was evident that residents’ rights would be upheld as far as possible, including being treated at the home rather than in hospital. The home had a health and safety policy statement and there was evidence from the records and in discussion with the manager and staff that safe working practices were in place. All accidents, injuries and incidents were wellrecorded and appropriate action taken. Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 x 18 4 3 x x 3 x x x 2 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.V307613.R01.S.doc Version 5.2 Page 23 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 The registered person must ensure that the person administering prescribed creams confirms by their signature. Omissions must be followed up and the reason recorded. The registered person must ensure that risk assessments for residents who self medicate are regularly reviewed. The registered person must ensure that all areas of the kitchen and unit fridges are adequately cleaned. The registered person must ensure that paper towels and liquid soap are available for staff hand washing in the designated facility for kitchen staff. Timescale for action 31/08/06 2. OP9 13(2) 31/08/06 3. OP26 13(3) 31/08/06 4. OP26 13(3) 31/08/06 5. OP37 18(1) The registered person must 31/08/06 ensure that staffing levels are adequate at all times to meet residents’ needs and ensure their safety. This is a repeat requirement Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 24 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 OP28 Good Practice Recommendations The registered person should ensure that 50 of care staff undertake NVQ level 2 training. Redbond Lodge DS0000017917.V307613.R01.S.doc Version 5.2 Page 25 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.V307613.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!